





rrr.%o j V'-^'V* "V^'V V^'V % 




.* </ ft 

***** ; ^lfe ^^ ; J1K: V** 
















a° *i^L'* * v % • • • <•- <^ ^o v s > * * % v v y » * • •- 'ck 

**- w : imM° ^ ; JBir ^ :,J 



' o » o ' 



1 - C.J 















? *+ -SIP/ A v *^ 






V c°. 















^0^ 




*bV" 






^\ 





















& 















;* .v 






,♦* 



'•"V /^W, 





>°-v 








x-s ***** -Mak' ^ 



* 









-4 o 

•V" 










* ! 



^* 


















. 






vv 






DISEASES OF THE SKIN 



DISEASES OF THE SKIN 

WITH SPECIAL REFERENCE TO PRINCIPLES OF TREATMENT 

TOR THE USE 

ADVANCED STUDENTS AND GENERAL 
PRACTITIONERS 



BY 

HENRY M. DEARBORN, M.D. 

I'rofmsor Late 



SECOND EDITION 



REVISED, ENLARGED AND EDITED BY 

FREDERICK M. DEARBORN, A.B., M.D. 

[Jem 

..».ira Pran 
pita 



WITH ONE HUNDRED AND THIRTY-FIVE ILLUSTRATIONS 
INCLUDING NINETY-EIGHT FUl.l PAGE ENGRAVINGS 



BOI Kl< Kl A RUNYON 

\l W YORK 
19 









^LIBRARY ot CONFESS? 
IwoCoB'e* riectiv-a. ' 

WAY 8 1908 



<>LA»S» M* Nu - j 

ooky a. 



IXc Nu. j 
»=-■ J 



Copyrighted, 1906 
By BOERICKE & RUNYON 



Received from 
Copyright Office. 



!7Je'08 



The Outing Press 
deposit, n. v. 



Cfjis *5>rronb Coition 

is brbiratrb t»» tfir 

<£ tutor 

tEo tl)f mrinorp of fjrr tofjo 

toitl) loumg interest 

toatcljrb ttjr progress of this fcuorb 






PREFACE TO THE SECOND EDITION 



While every attempt has been made to bring this edition up to date 

in all departments, none of the original feature- have been shelved, and 
conciseness and brevity arc as before, coupled with a self-evident system 
of simplicity. No better explanation of tin- objects in view in the prepa- 
ration of this treatise can 1m- offered than the following paragraph from 

the preface to the first edition: 

"The besl method of studying disease is that which yields the mosl 
practical information a- to the causes, nature, course and symptom- of a 
given malady and the therapeutic measures required for it- -afe and speedy 
relief or cure. The aim in the following pages ha- been to furnish the 
entials of skin diseases in such form as to be clear and accessible to the 
-indent and general practitioner- especially a- indicating principles or 
mean- of treatment. Hence etiology, symptomatology and diagnosis are 
given more prominence than pathology, not because the latter is lacking 
in interest, bul rather that it i- of leasl importance in a work not designed 
for the use of specialist 

In the preparation of this edition, every page ha- been revised ami 
many portion- rewritten, particularly those sections dealing with pathol- 

and treatment. Tin eneral classification is retained, although 

a number of di- igned to different groups because further in\ 

tigation ha- established their real nature or because original research has 
demonstrated something specific in their character. Possibly one of the 
most important addition- to this edition will he found under the general 
remark- on treatment iii Pari I. and ileal- with phototherapy, radiotherapy 
and other physical agents. A further discussion of these subjects will be 
found in the sections devoted to the treatment of those diseases which call 
for these method-. Part III i- added to embrace a brief consideration 
of internal therapeutics, a- shown by a discussion of the action of drugs. 
The remedies are arranged alphabetically, and being all grouped together 

make the matter of reference much simpler and obviate the necessity of 
frequent repetition. Again quoting the preface to the original edition: 
"It is hoped that a brief statement of the general sphere of action of drugs 
may .-how the adaptability of some remedy to one of the varied assem- 
blages of the phenomena of disease presenting from time to time: most of 
the indications given have been verified, many of them by the author. 
8 mc of the illustrations of cutaneous diseases serve the double purpose 



\ iii PREFACE TO THE SECOND EDITION 

of depicting objective lesions and the principles of treatment related to 
their cure. An ideal in therapeutics has been striven for, though far 
from attained, yet sufficiently demonstrated in practice to justify the belief 
in its practical utility in the art of dermatology." 

Seventy new illustrations are presented in this edition, the majority 
being from photographs taken by the editor, and the following new sub- 
jects are introduced: Radiotherapy, Phototherapy, High Tension and 
Frequency Currents, Becquerel Rays, Vibration and Mechanical Vibratory 
Massage, Monilethrix, Lepothrix, Tinea Nodosa, Rontgen-ray Dermatitis, 
Dermatitis Gangrenosa, Varicose Ulcer, Atrophia Cutis, Atrophia Senilis, 
Kraurosis Vulva?, Echinococcus, Demodex Folliculorum, Dhobie Itch, 
Blastomycosis, Myringomycosis, Colchicum, Cuprum Arsenicosum, and 
Fagopyrum, while many other sections have been completely rewritten. 

The editor desires to acknowledge the courtesy of those colleagues 
who have assisted in any way in the revision of this work, especially the 
resident physicians of the metropolitan hospitals which the editor attends. 
Frequent reference has been made to the standard works on diseases of 
the skin, both of foreign and American authorship, also to the current 
medical journals, especially to the Journal oj Cutaneous and Venereal 
Dist-ases. 

It is hoped that the form and appearance of this volume, the mechan- 
ical changes, and such additions as a lapse of three years demands, will 
meet the approval of the profession. 

FREDERICK M. DEARBORN. 

New York City, 

146 West 57th Street. 



CONTENTS 

TART I 
GENERAL PRINCIPLES 



ANATOM* 

'■'• 

avu ... 4 

Erancsiua ............. 5 

6 
Si douf ' 

II mi:- s 

11 

Blo 1- 

Li M-ii LTioa 12 

Ni I 13 

Mi 14 

COLOB . 15 

rin 8101 1 

16 
16 

Ih 17 

1" 
I s 

M MI'KiM kTOLOOl 

18 

Mai J'» 

I'M -'I 

Will M- 

_'J 

\ i 88 

23 

_'i 
l\ 

cm - i - 25 

1~> 

■2:> 

I . • ...... 26 

i i, 26 

i \ --ii in. I.i -i<'\- 26 



X CONTENTS 

GENERAL FEATURES OF LESIONS PAGE 

Patches 26 

Size and Shape of Lesions •. 27 

Eruption 27 

ETIOLOGY 

Predisposing Causes 28 

Direct Causes 32 

DIAGNOSIS 

Patient's History 35 

Symptoms of Disease 35 

Lesions 35 

Effects 37 

Causes 37 

TREATMENT 

Causal 3S 

Physiological 39 

Pathogenetic 39 

Mechanical 40 

Operative 42 

Instruments 42 

Electricity 44 

Radiotherapy • 44 

Phototherapy 40 

Becquerel Rays 48 

High Tension and Frequency Currents 49 

Vibration and Mechanical Vibratory Massage ; 51 

CLASSIFICATION 

Class I. Diseases of the Cutaneous Appendages 54 

A. Sweat Glands 54 

B. Oil Glands 54 

C. Hair : .14 

D. Nails •">."> 

Class II. Idiopathic Affections 55 

Class III. Diathetic Affections 55 

Class IV. Neuropathic Affections 56 

Class V. Parasitic Affections 57 

A. Animal Organisms 57 

B. Vegetable Organisms 57 

Class VI. New Growths 58 

A. Benign Connective Tissue Growths 58 

B. Benign Epithelial Growths 58 

C. Malignant Epithelial Growths 50 

D. Malignant Connective Tissue Growths 59 



CONTENTS xi 



PART II 
SPECIAL DISEASES 

CLASS I. -DIS] OF THE CUTANEOUS APPENDAGES 

A.— DISl ! I UK n\\ EAT GLANDS 

i-i.. i 

\mi>H"-i~ 80 

Hyfbbidbosu til 

Bbomidbosu 82 

I i: <;:i 

i Ihbokidwmu 64 

Hi mm ii>ici-is (i:> 

Pbmphoh -< i m Sweai <i."> 

Bnw ! BTOM \ 68 

Mm iu; i una t;t; 

Mii.iaui k Rl BBA liT 
llvi>li U>l il-i BATH v 

i: Hi- 1 HE "II. GLANDS 

Ibteatosih 70 

-i BOBBBa \ 7 • » 

'.'•iciciih n Di ii\i \ 1 1 1 1 - 7:> 

IIDO 80 

Mi i.i i \i 

\< M \ i I -. \Kl- 84 

\i M \ tBIOl DOBMU 91 

i»i-i USES OF i hi: h \ii; 

llvriitiun BOB] 92 

Tick hi \~i- 95 

Dim H HIASU 95 

1'it \.. ii [TAB i i:i mi \i . . . 95 

I HOttBBXIB MOOOH \ '■"'> 

m«pmi etrbix 97 

i.iimiiiuix . 98 

Tim \ NfODOfl \ 98 

I'ui'itv .... 98 

I \MMI- 99 

Plica . i<»<> 

An. ii i i \ LO] 

\i "ii I I \ \i:i v i \ l""i 

Poi 1 1« i litis Decalvahs . 1 n» 

Di i;m \ I II Is Pun I LBIB i M-ll.l HIT 112 

iikmi StTPUBATin Pebdoixm 113 



xii CONTENTS 

D.— DISEASES OF THE NAILS 

PAG E 

Onychauxis 114 

Pterygium .- - 115 

Onychomycosis 115 

Atrophia Unguis 116 

Spoon Nails 117 

White " 117 

Reedy " 117 

Onychia 118 

CLASS II.— IDIOPATHIC' AFFECTIONS 

Lentigo : 119 

Chloasma 120 

Erythema Simplex 124 

Erythema Neonatorum 124 

Erythema Intertrigo '. 124 

Erythema Traumaticum 126 

Erythema Caloricum 120 

Erythema Scarlatiniforme 127 

Erythema Exudativum 130 

Erythema Multiforme 130 

Erythema Iris 132 

Erythema Nodosum ' 133 

Dermatitis 136 

Dermatitis Calorica 137 

Dermatitis Traumatica 141 

Ron'jgen Ray Dermatitis 141 

Dermatitis Medicamentosa ' 142 

Drug Eruptions 142 

Vaccination Eruptions • 150 

Dermatitis Venenata 152 

Feigned Eruptions 153 

Trade Eruptions 1 54 



CLASS III.— DIATHETIC AFFECTIOXS 

Eczema 156 

Psoriasis 177 

Dermatitis Exfoliativa 1S7 

Dermatitis Exfoliativa Epidemica 191 

Dermatitis Exfoliativa Neonatorum 192 

Dermatitis Gangrenosa 194 

Multiple Gangrene 194 

Hysterical Gangrene 194 

Diabetic Gangrene 104 

Dermatitis Gangrenosa Infantum 195 

Varicose Ulcer 190 

Pityriasis Rosea 198 

Lichen 200 

Lichen Ruber 201 



CONTENTS xiii 

PAG! 

LlCIIK.V Pl.ANl'S 205 

Pakakkka tonis VaRXEOATA 208 

KERATOSIS Pilaris 209 

Ki.I'.ai :us 210 

Keratosis Pauubu bi Pla.ntakis 211 

icbthtosis 21:5 

si i.kk1 ma nconatordm 217 

(Edema Neon itori m . 218 



• LASS [V.— NEUBOPATHIC AFFECTIONS 

BT Dim i RBAXI BS . 220 

Hyperesthesia 220 

AJMMtheaia 221 

I'm 221 

matalgia 221 

Pki BXTtJS 222 

l*Ul RUM 22li 

Urticaria 229 

- \ 

*A 233 

Pi IF) U 

239 

III RPBS 242 

- I \i LAXJfl 

211 

Hi mi 245 

roams 260 

I Mil I I .ii III R|>| l II ORMIfl 264 

D 265 

i km \i ii i- Pn 256 

Pi i i LORA 2.">7 

■i \i \ 

IIVI.U >\ 

Pomphoi \ \ 200 

Pi mii 2H1 

s« 1 1 booi i:m \ 268 

Dn i i -i ii Btmhetu i \ 268 

I lid I USCBIOl D I 271 

2 7:i 

ism 274 

Vim mo 27 1 

276 

277 

Atrophia Maculosa n Striata 277 

Kit A I HUMS Vl |A I 278 

27s 

or the Fooi 279 

Trophic Ulcers . 280 

SVMMIIItKM 1 ,li;iMIMI> 280 

A I Ml I M 28] 

Sybini 282 



XIV CONTENTS 

CLASS V.— PARASITIC AFFECTIONS 

A.— ANIMAL PARASITIC DISEASES PAGE 

Scabies 283 

Pediculosis Capitis 288 

Pediculosis Corporis 290 

Pediculosis Pubis 292 

Pulex Irritans 293 

Pulex Penetrans 293 

Cimex Lectularius 294 

Culix Pipiens 294 

Apes Mellifer.e 294 

Simulia 294 

Yespid^e 204 

Leptus Autumnalis 294 

Ixodes Ricinus 294 

Dermanyssus Avium 295 

fllaria medinensis 295 

Cysticerus Cellulose Cutis 296 

Echinococcus 296 

Demodex Folliculorum 297 

B.— VEGETABLE PARASITIC DISEASES 

Favus 297 

Tinea Trichophytina 302 

Tinea Circinata 303 

Tinea Tonsurans 303 

Tinea Barbae 305 

Tinea Versicolor 315 

Tinea Imbricata '. 318 

Erythrasma 320 

Dhobie Itch 321 

Blastomycosis 322 

Myringomycosis 323 

Pinto Disease 323 

Actinomycosis of the Skin 325 

Mycetoma 32S 

Impetigo 330 

Impetigo Contagiosa 332 

Ecthyma 334 

Sycosis 336 

Furunculus 341 

Carbunculus 344 

Anthrax 347 

Dissection Wounds 350 

RlIINOSCLEROMA 351 

Oriental Boil 352 

Phaged.ena Tropica 353 

Elephantiasis 3.54 

Tuberculosis Cutis 358 

Tuberculosis Cutis Orificialis 359 



CONTENTS xv 

PAGE 
TCBEBCULOSIS VSBBUOOSA .ilil 

Li Ft B \'l LOABU3 363 

Scbofi LODEBMA 369 

I.K MhN >( BOl i 382 

Ebytiikma Imh KATL.M 383 

Syphilis 

-42!! 

*> A.W8 .... 4411 

Kyi ima 442 

B*T«P1 LAS 444 

PELOID 447 



CLASS \ [.—NEW GROWTHS 
A.— BENIGN CONNECTIVE TISSUE GROWTHB 

I tnOM v 44!» 

J\i I'.iu 451 

( l< ATMX 152 

JLuri boh v 453 

XAHTuOMA iMI-lil ll« <i|; i 4.V! 

I.I ' M \ 

liTOM I 456 

Nil BOM v 456 

A\<.i..\i \ 157 

4.")7 

II. I 

I elungii 

Angioma Sei piginiaum 

An 

1.1 Mill \ IOIOM \ •'•I 

in:; 

\i \ s i Hoaia Nil km i\. nil 

Mi ae 465 

i ..I i oio |i;: ' 

l.i i 466 

Myxikdiima . 171 

\ ■ , . ... 472 



B BENIGN EPITHELIAL GROW rHS 

473 

474 

4 ~ ;) 

l\n;\; *76 

\ 177 

I'.MII I'M \ I I II- '"" 

Mm LI SCUM COW! LGIOSI II 4M 

Mi i.i i ii i Bsxioif Ctstk EPITHELIOMA 182 

*83 

,M 



I Ml 



xvi CONTENTS 



C— MALIGNANT EPITHELIAL GROWTHS PAGE 

Cancer ,. . . . 48G 

Epithelioma 48C 

Rodent ulcer i 487 

Paget's Disease of the Nipple 4S8 

Carcinoma Cutis 494 

D.— MALIGNANT CONNECTIVE TISSUE -GROWTHS 

Sarcoma Cutis ., 495 

Mycosis Fungoides 498 

Xeroderma Pigmentosum 500 

Verruga 502 

PART III 

INTERNAL THERAPEUTICS 

aconitum 504 

Agaricu s 504 

Agnus Castus • 505 

Aloes 500 

Alumina 506 

Ailantiius '. 507 

Ammonium Cabbonicom 507 

Ammonium Muriaticum 508 

Anacardium 508 

Anthracinum 509 

Antimonium Crudum .- 509 

Antimonium Tartaricum 511 

Antipyrine 511 

Apis 512 

Argentum Nitricum 513 

Arnica 514 

Arsenicum Album ■ 515 

Arsenicum Bromatum 519 

Arsenicum Hydrogen 51!) 

Arsenicum Iodatum 520 

Asterias Rubens 521 

Aurum 521 

Aurum Muriaticum 521 

Baryta Acetica 522 

Baryta Cabbonica 522 

Baryta Iodata 522 

Baryta Muriatica 

Belladonna 524 

Benzoic Acid 526 

Berberis 526 

Borax 527 

Bovista 528 

Bryonia 529 

Bufo 531 



CONTENTS xvii 



« AI MM II Bl 1.1 I KATIM 531 

AUUM 532 

< au.il m Salts 532 

( Al.rAlUA Acetica 533 

I ai.c uu.a ( ABBONICA 533 

' LLCARKA Fl.lOHATA 534 

i aliakka Phosphoric* 535 

t AM ABBA Si I.I-IH l:i< \ 53fl 

Cannabis [hdica .v;; 

< AVrilABIS .-,.{S 

< ABBO AmmaI i> 5;5<) 

1 Iabso Vegetabxus ... 539 

001 [0 At lii .")40 

' Al Ml. 1 M ........... .">41 

1 IIi.UDo.Ml h .... 542 

( MINIM M Si I.IMIl UH I M .-,4.°. 

Cm.oKAi.1 m ;,44 

\ :,4."> 

:>4.") 

LATIS . ."itli 

:>4i; 

i '•> ■ .".47 

i iih i m 548 

I • i • Hi' ink . ;,ts 

10 LABIA 549 

I'M :>4!i 

M . \ . ... ."i.'ill 

' IIIUWU ."l.'ll 

- IllUCIillil I ."l.'ll 

i i'. i mm ....... "i">:> 

563 

< i FBI v. "i">4 

t I HAH! ."..")4 

I 111 UIIN 555 

Dn.i i LLM 555 

Di I < AMABA 558 

ion \i U)t a iii i si . 557 

Bl PHOBHl m ... 557 

I LOOFYBI m 557 

li i OUd M At ini If ........ .... ... 558 

< ;i(\i-iii ii - 550 

in 1 1 1 noil - Nun k ... . 561 

IIh-mi Si i.i'in it . . 561 

IIyiu; 1Mb 564 

llvmiu. on i i A-i vi u a 565 

HViiSi V AMI - 566 

llvi'i iiu i H ... 567 

[an lob . :,(;s 

.1 ami in win 569 

■li 0LAK8 I IM in A 569 

JUQLAHB lU'.l \ . 570 

K.vi [DM 8AI.T8 ... 570 

Kai.i BICHBOHK i M . 571 



xviii CONTENTS 

PAGE 

Kali Bromatum 572 

Kali Caebonicum 573 

Kali Iodatum , 574 

Kali Mleiaticum 575 

Kali Phosphoricum 570 

Kali Sllphuricum 577 

Kalmia 578 

Keeosotum 579 

Laciiesis 580 

Ledum 581 

Lycopodium 582 

Manganum 584 

Meecueius • 585 

Mebcleils Biniodidus 587 

Mebcueius Cobrosivus 588 

Mezeeeum 588 

Mleiaticum Acidum 590 

Nateum Salts 591 

Natrlm Arsenicatum 592 

Natrlm Muriaticum 592 

Natrl m Piiosphoricum 595 

Natrlm Sulphuricum 596 

Nitrlm Acidum 590 

Nux Moschata 598 

Nux Vomica 599 

Oleander 599 

Opilm 600 

Osmium 001 

Paris Quadrifolia 001 

Petroleum 601 

Phosphorus 603 

Phosphoricum Acidum 605 

Phytolacca 606 

Picricum Acidum 607 

Populus Candicans 608 

psorinlm 608 

Pulsatilla 609 

Ranunculus Bulbosus Olo 

Rhododendron 011 

Rhus Toxicodendron 011 

Rlmex C'rispus 013 

Sabina 014 

Salicylic Acid 615 

Saesapaeilla 615 

Secale 010 

Selenium 617 

Sepia 617 

Silicea _. 019 

Spigelia 022 

Staph ysagria 022 

Stillingia 024 

Sulphur ci-24 

Sulphueicum Acidum 627 



CONTEXTS xix 

PAGK 

Tabexti i.a Clbexsis 02S 

Telia bum 628 

Thlil KIMHIXA l!2!l 

Thuja 629 

Ubtica Ubexs 631 

Vespa 632 

VlXCA MlXOB C33 

\ ioi a Tbicolob C33 

\ II-l.KA (134 

II 634 



LIST OF ILLUSTRATIONS 



FIO. 

1 Section <>i mi. hi man skin page 2 

2 Buaoi ta.neoi B i ai H88DI page 3 

- QLAJfDfl 01 tiil BBOOHD class page 7 

4 BV i BOB "i Bfl N \ I iiaib and ns koi.lici.e page 9 

5 Ei'iLATi.NG i "H< Wn page 42 

6 Elk( tkoi.yth Kirm page 42 

7 liniwi'miM ii Minu page 43 

9 1'iiiabd's OBAl-riiM. KM page 43 

9 PlVTABD'fl ■ 'iB page 43 

10 Milium page 43 

1 1 Scabikvi.no sim u page 43 

12 NEEDLE h>b bkmowng iiaib R ki.i ci bi>i.y-i> page 43 

IS N i u page 43 

14 Pin abii'.-, dkbmai. o bi in page 43 

15 Hi iitviMiiiK page 43 

16 Aim i. vmii \m> OOMEDON1 i x i u v< i< >it paye 43 

17 Ei.m title iaiumi page 44 

1« Fbii hi vsi'i.ii inxpi) page 45 

19 CBOOI page 46 

( boom page M 

_• 1 (bimiki's ii in page 4«; 

_'_' s aim'abatls page 47 

II QLAM \ aci i m ELaonooM page 49 

!i:ai. -ii mi i. olam rAOOtm Btaunon page 50 

ii ui.ab A' bay ii be* page 51 

lii'iiiic KOTO! page 51 

■J7 M.niiBiiini:ir i>ibm\iiii-. facing page 72 

"Uuiki.m in km m in- facing page 73 

BnOMHOW I'MtMMlii- .... facing page 70 

BnOSUKHI imummiii- . facing page 77 

31 Acne WUUMU facing page 84 

:<J (omiiiii m-.i-i.i\ facing page 104 

33 AlAPBOU Mil ma facing page 105 

34 Auii'i i i a uti m \ facing page 108 

S8 Ainrnh abi aia facing page 109 

36 AIM < i v .Mil \ i \ facing page 109 

37 Chloasma facing page 120 

\ facing page 120 

\ facing page 121 

K) I Bi i in m \ s. Mu \ i imi 0B1OE facing page 127 

41 Ebyiiiim\ mi i.inuBME facing page 130 

42 Ebytiiimv mi i iii.iitMi facing page 131 

43 Debmai I rn venenata facing page 152 

il I ii vi m: ii facing page 153 

45 Eczema facing page 158 

46 Eczema facing page 158 



xxii LIST OF ILLUSTRATIONS 



FIG. 



•> 



47 Eczema facing page 159 

48 Eczema facing page 162 

49 Eczema facing page 163 

50 Eczema ' facing page 166 

51 Eczema facing page 167 

52 Psoriasis facing page 178 

53 Psobiasis facing page 179 

54 Psoriasis facing page 180 

55 Psoriasis facing page 181 

56 Psoriasis facing page 184 

57 Psoriasis facing page 185 

58 Hysterical gangrene facing page 194 

59 Lichen ruber facing page 202 

60 Keratosis of the sole facing page 210 

61 Keratosis of the palm facing page 211 

I 62 Ichthyosis simplex facing page 214 

63 Ichthyosis hystrix facing page 215 

^~~~ 64 Prurigo facing page 226 

65 Purpura simplex facing page 234 

66 Purpura simplex facing page 235 

67 Herpes zoster facing page 246 

68 Herpes zoster facing page 246 

69 Herpes zoster facing page 247 

70 Dermatitis herpetiformis facing page 250 

71 Dermatitis repens facing page 255 

72 Pomphoxyx facing page 260 

73 Pompholyx facing page 261 

74 Pemphigus facing page 261 

75 Leucoderma facing page 274 

76 Leucoderma ' facing page 275 

77 Acarus scabiei (female) page 285 

78 Acarus scabiei (male) page 285 

79 Pediculus capitis page 289 

80 Pediculus corporis page 289 

81 Pediculus pubis page 289 

82 Favus facing page 298 

83 Favus facing page 299 

84 Favus fungus page 299 

85 Tinea circinata facing page 302 

86 Tinea tonsurans facing page 303 

87 Tinea tonsurans facing page 304 

88 Trichophyton fungus page 306 

89 Tinea versicolor facing page 315 

90 Fungus of tinea versicolor page 316 

91 Fungus of erythrasma page 320 

92 Actinomyces page 326 

93 Actinomycosis of the skin facing page 326 

94 Actinomycosis of the skin facing page 327 

95 Impetigo contagiosa facing page 332 

96 Impetigo contagiosa facing page 333 

97 Ecthyma facing page 334 

98 Ecthyma facing page 335 

99 Sycosis facing page 336 

100 Sycosis facing page 336 



LIST OF ILLUSTRATIONS xxm 

FIG. 

101 Elephantiasis facing page 354 

102 Tuberculosis okukiaus et verrucosa facing page 360 

103 Lupus vulgaris facing page :>oi 

104 Lupus vulgaris facing page 304 

105 LUPUS vulgaris facing pagt 365 

106 Lupus vulgaris facing page 308 

107 Lupus vulgaris facing page 369 

108 Scrofuloderma facing page 370 

109 Scbohloi . s i.aciyi.uis facing page 371 

110 Secondary BTFHUUDIi facing page 394 

111 Secondary sypiulide facing page 395 

112 Moist papular sypiulide facing page 398 

113 Purpuric sypiulide facing page 414 

114 Tertiary syphilide facing page 415 

115 Leprosy facing page 430 

110 LCFBOn facing page 431 

117 Leprosy facing page 434 

118 Leprosy .... facing page 435 

119 Leprosy . facing page 438 

120 Leprosy faring page 439 

121 Fiiikoma M'h.i.i BCUU facing page 448 

122 Fibroma PDTD1 l.i M . facing page 449 

123 Kii.oid ...facing pu 

124 Cicatrix facing pa* 

12.~> l.i ii I i KYiiu.MAloM - . lacing page 466 

120 LUfllS miJUMATOBUI .. facing page 467 

127 NSUBOPATHIO papilloma facing pa> 

128 Ki-ii in LION ^ facing pu • 

129 KPIIHU.IOMA facial/ pa- 

180 Kin in. i.ioMA . facing page 487 

131 I'M.i r> i. . . facing pw 

132 Cam i- } ii,\iuj paj 

133 Primary in. mi i page 496 

■ '- 

135 IfTOOaa n mm I facing page 499 



PART I 

GENERAL PRINCIPLES 

ANATOMY 

The skin is an organ complex in Structure ami with active ami 

passive functions. As a fibro-elsstic membrane it affords : 
and protection t" ti • s with which it is intimately related 00 

one 6ide, ami receives impressions from the outer world to which it is ever 
exposed on the other. 

The skin beantinea the human fori' roundness b 

and curves of the body, ami for this ami m thickness 

in dilTi us. It buttock*, the palms of the hand- 

■ad !id thinnest on • ml pre; • nerally 

ir tissue is i se deposit normally 

riant of d t-> tin- par' !i is close and firm, and 

mobility is limited. Where mobilit and tin 

there is litt Cat, and 

The most external thelial i 

The i in al, also pigment, which ^ivea 

color to the .-kin in var liferent indiridu 

and under d 

hith, a- Dp into ]»dvimirphou8 

mtlv. and U6uall> invisibly, thrown "!T, ami ai otly 

in within. Thus the epithel :in in health is 

■air by it.- own in-dwelling protoplasm, but l>y tl 
jiarative impermeability by a uatui 

of the fkin. wh: Dually ai a !<arrier to a 

too rapid loss of Quids from • ee within and, in I 

prol om irm . and t! of 

in without Within tb this en 

i forming an integral pari u ity 

for mportant and varied functions, When fully dei ikin 

thus becomei an organ of sens 'inn, of 

absorption, and by co-ordiru ■ regulator of I mic temperature 

and an adjust' t elementa of the I 'rgan in 

the body has so many functions to perform, and none is so continuously 



ANATOMY 



exposed to deleterious influences. Hence the fact that the skin is peculiarly 
liable to injury and disease. The skin of the face may be said to reflect 
to a considerable extent the conditions of body and mind. Here the ob- 
serving clinician looks for signs of health or disease. The pallor of exhaus- 
tion or chronic illness, the flush of fever or of unusual vigor, the shadows 
of despondency or fatigue, the marks of dissipation, the play of the emotions 
are more or less mirrored in the skin of the face, and lend significance to 




Fig. 1. — Section of the Human Skin. 
1. Subcutaneous tissue. 2. Corium. 3. Epidermis. R, Reticular layer of the coriurn. 
P (on cut), Papillae of the corium. M, Mucous laver of the epidermis. G, Granular 
layer of the epidermis. C, Corneous laver of the 'epidermis. S. Sebaceous Gland. 
T (on cut), Sweat Glands. H, Hair. JV, Tactile corpuscle. A, B, F, Capillaries 
supplying fat lobule, sweat gland, papilla of the hair and papillae of the corium. V, 
Veins from the papillae of the corium. E, Erector pili muscle. ( Diagrammatic. ) 

his practiced eye. The skin and its functions are essential to the life of the 
individual. One may lose an eye, a kidney, be deprived of those organs 
essential to a reproduction of the species, and yet may enjoy for a long time 
comparative health; but if the functions of the skin be long suspended, or 
if any considerable portion of it be destroyed, health is impossible, life 
doubtful. 



ANATOMY 



In order to comprehend the nature of the changes produced in the skin 
by diseases and the curative action of remedies, a knowledge of the anatomy 
and physiology of the skin is necessary. With the aid of the microscope, the 
skin is found to be composed of two constant organic parts, the corium and 
the epidermis, and several less constant parts, termed the "appendages of the 
skin," the sebaceous glands, the sweat glands, hairs, nails and pigment. The 
skin also contains blood-vessels, lymphatics, nerves and muscles. The corium 
is the original foundation of the skin. By the continuous deposit of fat in 
the innermost layers of the corium during foetal life, the subcutaneous 
areolar tissue is formed. Embryo] . therefore, that this is a part 

of the corium, but as the border-line from the deposit of fat is apparent to 
the naked eye usually considered as a separate layer of the skin. 

-H - T188UB.- -The sub- 
cutaneous tissue (l. Pig. li is 00m- 

d of a network of fibrouc 
tive tissue which is attached mn 

firmly to the periosteum or super- 
ficial fascia and 
rections outward, to m> < 
tibly in the - :iuni. 

thus formed are filled 
with fat S queni to birth, t! 
is gradually absorbed 

mobility, such as over the 
d, or firm attachment, n* 
tin- larger portion of tin- ear, are 

•itial. The inu-r-fascic-ular spaces 

rtitute tin- paw 
The fat globules are clustered in 
ma--.'-, forming lobuli - of ..irious 
Bach lobuli- is supplied witli a 
capillar} an afferent artery and 

an efferent vein. In some thicker por- 
tions "i the skin columns of fat pass 
obliquely into the lower two-thir 
tlio curium. They are believed 
increased support and elasticity to the 

I'm- the passage of blood- and lymphatics, and at 

in the nourishment of glands. Imbedded in the subcuutnc-ou 
the sudoriferous -land- and the deeper-seated hair follicles. The blood- 
vessels supplying the* are large and send off branches to the 
corium. The Bubcutaneous tissue contains lymphatics and nerves. Some 
of the latter terminate in the Pacinian corpuscles, The Bubcutaneous t 
in its normal condition gives form and plumpness to the body and serves as 




Fi< 






H. bundles of filirou;. connective ■ 

globules with mxli i. 
M giuued about 500 diameters. (Diar 

niiiKitic after H< itzrnuiin. ) 



4 ANATOMY 

a double cushion — first to the parts beneath which are liable to pressure, 
and, second, to the more delicate corium externally, as well as the appendages 
seated within and passing through both layers. In starvation and wasting 
diseases the contents of the oil globules disappear, leaving the cell-wall intact. 
These rapidly refill again with the return of nutrition. An abnormal pro- 
duction and deposit of fat leads to obesity, so that the subcutaneous tissue 
may become an inch or more thick. 

Corium. — The corium (2, Fig. 1) is the most important portion of the skin. 
It is composed of a closely arranged network of white fibrous tissue, with 
yellow elastic and muscular fibres in intimate association. The inter-fascicular 
spaces are smaller than in the subcutaneous tissue, and lessen in size towards 
the surface. They contain lymphoid corpuscles, connective tissue cells and 
oil globules. The corium is abundantly supplied with blood-vessels, lym- 
phatics and nerves. Its thickness varies in different individuals and on 
different parts of the body. In the thickest portions, as over the soles of the 
feet and the nates, its substance is penetrated by columns of fat heretofore 
mentioned. 

An arbitrary division of the corium is usually made into two layers, the 
lower or reticular layer and the upper or papillary layer. The reticular layer 
(R, Pig. 1) is composed of white fibrous tissue, which, in the deepest portion, 
separates in bundles without division, forming a distinct net; but, as they 
proceed upwards, the bundles of tissue divide and subdivide, until they reach 
the upper layer and there form an interlacement by numbers of single fibrilla?. 
The larger spaces in the reticular layer are filled with fatty tissue, blood- 
vessels, nerves, lymphatics, the outwardly opening sudoriparous ducts and 
deeper hair follicles. The smaller spaces contain connective tissue, corpuscles 
and wandering cells. 

The papillary layer is distinguished from the lower layer by its more 
intricate structure. The inter-fascicular spaces are so minute in places as 
to present a homogeneous appearance. The superficial surface is made uneven 
by countless projections called the papillae (P, Fig. 1) of the corium, which 
dovetail with the downward growths from the epidermis. The papillae are 
simple when there is one tuft or compound, when two or more projections 
spring from a single base. They may be conical, club-shaped, or square. 
They vary also in number and size in different regions. They are most highlv 
developed and numerous on the tips of the fingers, palms of the hands, soles 
of the feet, the nipples, clitoris, glans penis, and labia minora. Meissner 
found four hundred in a square line at the tip of the finger, and it is 
estimated that the whole skin contains one hundred and fifty to two hundred 
millions. 

The importance of the papillae is due to their being the residence of the 
terminal expansions of the cutaneous nerves and vessels. The vascular 
papillae are supplied with afferent arterioles (plexus) and an efferent vein. 
The nervous papillae contain medullated nerve fibres and one or more tactile 
corpuscles. Occasionally a papilla is provided with both blood-vessels and 



ANATOMY 5 

nerves. The papillae of the corium are separated from the epidermis by a 
thin basement substance. 

Epidermis. — The epidermis, cuticle or scurf skin (3, Fig. 1), is the most 
external layer of the skin. It is entirely cellular in structure and contains 
no blood-vessels, and only a few nerves in the innermost part. The junction 
between the corium and epidermis is nearly a straight line at about the middle 
period of foetal life. During the latter part of foetal life the epidermis grows 
flown ward by linear processes into the corium and, as the capillaries in the 
papilla? develop, centre.-; of nutrition are established for the epidermis. The 
full development and inter-relations of the papillae and epidermis, however, 
are not attained until after birth. The minute furrows on the surface of 
the skin illy noticeable on the back of the hand, are due to the depres- 

sions of the epidermis between the papilla?. The coarser furrows, as seen 
upon the back of the ne. -or surfaces of the joints, forehead and other 

pan face, are due to repeated tensions or muscular tractions of the 

skin. In origin the epidermis is quite independent of the corium. It has 
its own ectoderm, and is not re_ omplete loss of this matrix. 

The epidermis if 1 into three layers, the mucous layer, the granular 

. and the corneous la; 

The stratum m the mucous layer, the prickle layer, rate Mal- 

phigii (M. Fig. I), is situated immediately above the papillary layer of the 
corium, and is moulded by its inter-papillary projections accurately to the 
roughened surface of the cerium. It is composed of layers of nucleated cells. 
The lower strata of eel all and oblong with oval nuclei, which are 

surrounded by granular pro! their !• ndicular to the 

surface of the corium: they have no (ell-wall, and BOmetin -trata 

ajppear a mass of protoplasm with scattered nuclei. The cells of the next few 
rows are la' n form, with well-defincd nuclei and a distinct cell- 

wall. They contain granular and pigmentarj matter. The more superficial 
n.ws of the muo p of still larger cells, mere granular, and 

flattened; and. generally, their axes assume a horizontal position to the 
cutaneous sue 

All ■ Qucous layer have chs c protoplasmic processes, 

which unite the cells to ■ died prickli s. Hence the nai 

prickle-cells or prickle I authorities to this part of the 

epidermis. The prickle irmly, but at the same time 

the body of epithelia are kept separated from each other by the so-called 
itance of the skin; which subs permits the free passage 
of nutritive material from the papilla of the corium, the ingrowth of nerve- 
threads, the immigration of white bi I corpuscles, and the counter-flow of 

lymph inwards to the inter-papillary depressions, thence to the lymph vessels 
of the corium. The epidermis contains no lymph proper and no 

blood-vessels. 

During oic life the appendages of the skin are formed by the 

nutritive pi. talixed protoplasm of this part of the epidermis; 



6 ANATOMY 

and, after birth, they are the source of the organic material of all physiolog- 
ical or pathological secretions. 

The stratum granulosum, the granular layer (67, Fig. 1), is made up of 
one to three rows of granular cells arranged next to the prickle cells of the 
mucous layer. In disease this layer may be increased to four or five rows of 
cells. They are attached to each other by short threads, which make the 
inter-cellular spaces much narrower than in the mucous layer, hence, nutritive 
material is only sparingly supplied to these epithelia. The cells of this layer 
are filled almost entirely with granular matter, to which "Waldeyer has given 
the name of kerato-hyalin. This substance, which first appears in isolated 
granules near the nuclei of some of the cells of the prickle layer, is greatly 
increased in and characterizes the granular layer. TJnna believes that to 
this layer the white race owes the color of its skin, and supports this belief 
by the fact that, before the appearance of the granular layer during foetal 
life, the outer portion of the skin is transparent, so the blood-vessels of the 
corium can be seen through it, and also, that the color at the border of the 
lips and the nail beds is due to the absence of the granular layer in these 
parts throughout life. The changes which occur in the cells of the granular 
layer, as they are progressively forced outward from the mucous layer, are 
necessary to further changes in the external layer of the epidermis, known 
as cornification. 

The stratum corneum, the corneous layer, the horny layer (C, Fig. 1), 
is the external layer of the epidermis and of the skin. By rapid changes the 
outermost cells of the granular la3 r er are transformed (by apparent meltino- 
of their granules into the surrounding cell protoplasm) into clear, transparent 
epithelia. The first two or three rows of cells, owing to their appearance 
under the microscope, are sometimes called the stratum lucidum. But, as 
they represent a stage in cornification, it does not seem wise to distinguish 
them as a separate layer. More externally, the cells are arranged in po- 
lygonal plates, with shrivelled nuclei and rudimentary threads, which still 
serve to connect the frame-work of cells with each other. Still nearer the 
surface the cells become lifeless, horn-like shells, lying parallel to the cuta- 
neous surface, the outer rows wrinkled and curled up, preparatory to being 
shed. According to Unna, cornification of the epidermis is not a complete 
process, but consists of an alteration of the periphery and connecting threads 
of the cells into horny tissue, which, after digestion of the central part of 
the cells, presents a honeycomb-like structure. No traces of the inter- 
cellular canals are found in the corneous layer. The hard, dry character of 
the cells of this layer is due to the presence of keratin, which is a verv 
hard and resistant substance. 

Sebaceous Glands. — The sebaceous glands originate during the third 
month of fcetal life from the mucous layer of the epidermis, which, from 
multiplication of the epithelia downwards, form the gland (S, Fig. 1). Thev 
are found imbedded in the corium everywhere except in the soles of the feet, 
palms of the hands, and the dorsal surfaces of the last phalanges of the fingers 



ANATOMY - 

and toes. They are racemose glands, simple or compound, and lined with 
round cell epithelia. They secrete an oily substance called sebum, which is 
produced by the simple process of slow fatty degeneration and rupture of 
the cells lining each acinus. The ducts are short and end in the hair follicles 
or open directly on the surface. They are divided into three groups accord- 
ing to their distribution. The first group, or "the glands of the hair follicles," 
are found in the skin of the hairy parts of the body, where they are very 
abundant and are connected with the hair follicles into which they discharge. 
Each hair is provided with two or more glands. The second group are chiefly 
found in the so-called non-hairy parts of the skin, or those portions supplied 
with lanugo hairs. These glands are larger in size and more complex than 
those of the first class. Their dm directly on the cutaneous surface. 

In the duct the rudimentary or lanugo hair follicle appears to be placed 




inda <>f tin- ><•<•<. ml Cla-vs. 

appendage to the gland A third group are Limited in number and are uncon- 
l with tin- hair follicles. They an' found in the areola of the nipple, 
labia minora ami vestibule in the female, and on the interna] Burface of the 
prepuce and corona in the male. The diachai sebum i- facilitated by 

the contraction of thi llorum a 

Tin: SuDORiPAfl glands. — The sweat gland 

(T, Fig. 1) consists "f B minute tube with a blind extremity coiled several 



» ANATOMY 

times upon itself and imbedded in the subcutaneous tissue; thence the tube 
passes as a spiral duct through the other layers of the skin to the surface- of 
the epidermis, terminating in a funnel-shaped opening or pore, which in 
many places can be seen with the naked eye. The sweat glands appear to 
originate subsequent to the third month of foetal life, by solid growths of 
epithelia from the mucous layer of the epidermis downwards into the deeper 
tissues, where they coil upon themselves; and, in the course of development, 
the central part liquefies, forming a tube. Unna believes that the true duct 
ends at the surface of the corium (or about the plane from which the solid 
growth began), and that the remaining portion of the tube outward is a com- 
mon outlet for exudations from the interstices of the epidermis and for the 
sweat. The sudoriparous glands are simple in structure. The outer coat is 
continuous with the basement membrane of the corium; the middle or epithe- 
lial coat is continuous with the deeper layers of the stratum mucosum; the 
inner coat, or lining, is a delicate cuticle. The sweat glands are each sur- 
rounded by a sheath of connective tissue and fat cells, which support and hold 
the tubes in position. The sudoriparous glands are present in great numbers 
in all parts of the skin, except the colored border of the lips, the glans penis, 
the inner surface of the prepuce, and the clitoris. They are most numerous 
in the skin of the soles of the feet and palms of the hands, where Krause 
estimates their number to be nearly three thousand to the square inch. The 
largest glands are found near the anus and in the axillae. The average length 
of a straightened tube is about one-fourth of an inch, and it is estimated that 
the total length of the coil-tubes of the whole adult skin is upwards of nine 
miles. 

The function of the coil glands is the secretion of sweat, which varies in 
quality in health from a clear watery fluid of the smaller glands of the 
general surface to the more consistent fluid containing fat globules and granu- 
lar matter from the glands of the axilla?, the meatus of the ear, and at the 
verge of the anus. 

The Hairs. — The hairs (H, Fig. 1) originate about the beginning of the 
fourth month of intra-uterine life by cylindrical, knob-like growths downwards 
of the mucous layer of the epidermis. Later, these solid epithelial growths 
are met by extensions of the connective tissue from beneath, and the papilla? 
are formed in cup-shaped excavations in the epithelial bodies. In the papillae 
are fine protoplasmic cells and loops of capillaries which supply nutriment 
to the hair-root or bulb. Continuous with the tissue of the papilla? and with 
fibres from the subcutaneous layer, bundles of connective tissue surround the 
root of the hair and run parallel with it in an oblique direction through the 
entire thickness of the corium. This tissue is interspersed with circular 
muscle-fibres, is supplied with arteries, veins and nerves, and is lined with a 
structureless homogeneous membrane, which does not contain either blood- 
vessels or nerves. The whole forms a fibro-elastic pocket known as the hair 
follicle, in which rests the hair, to the base of which is attached the erector- 
pili muscle. 



anatomy 



9 



With the development of the papillae, the elements of the hair are formed 
by growth of the medullary epithelia about the papilla?. Gradually, by elonga- 
tion and compression of the epithelia, the hair is pushed outward to the sur- 
face, where it first emerges at about the sixth month of intra-uterine life. 
The portion of the hair in the skin is called the root, and the portion external 




Stratum Malpighii of outer root-sheath. 

I 



Cuticle of hair. 
-Cuticle. 
- Huxli v- 

Henle'a layer \ 



\ Inner 

} - root- 

layi r ' sheath. 



-v layer. 

! cells of 
the outer rool- 
ith. 



Medulla of hair 



Cortical ■ub- 

: hair. 



Hair-bulb. 



- Hair papilla. 
.. Blo...|-ves8eL 

-\ layer of 
hair-bulb. 




Conni 

of th>- 

Mil 



Fig 4 Longitudinal Section >>f Human Hair and Its Follicle. 

in mi'l Muvi'li.fl: x about 300.) 



10 ANATOMY 

from the skin is called the shaft. The root of the hair is provided with two 
coverings, the outer root-sheath and the inner root-sheath. 

The outer root-sheath is composed of epithelia, which are continuous with 
similar epithelia which form the sebaceous gland. It extends from the inner 
border of the pouch of the latter downwards, and ends near the bulb of 
the hair. 

The inner root-sheath is made up of granular polyhedral epithelia (for- 
merly divided into Henle's and Huxley's la}^ers), which, in the inner part, 
become somewhat elongated. The protoplasm of the cells of this sheath con- 
tain Tcerato-hyalin, which promotes the cornification of the hair tissue. The 
inner root-sheath covers the papilla, forms the bulb of the root of the hair, 
and extends upwards to the neck of the follicle. According to Heitzmann, 
the hair is produced by this sheath alone, by a solid elongation of the epithelia. 
The inner root-sheath is separated from the outer root-sheath by a thin mem- 
brane. Between the inner root-sheath and the main mass of the hair, TJnna says, 
there is found the matrix from which is formed both the cuticle of the root- 
sheath and the cuticle of the hair. The cells forming the cuticle of the root- 
sheath are arranged with their axes on a line with the circumference of the 
hair, while the cuticle of the hair is composed of cells which gradually become 
columnar in shape and lie parallel with the length of the hair. As the root 
nears the surface the cuticle of the hair appears to be formed of imbricated 
scales with elevated edges, which, in the shaft of the hair, gives it the charac- 
teristic serrated appearance. The central or cortical portion of the root of 
the hair is composed of delicate fusiform scales, firmly attached to each 
other, which give to the hair its great strength and elasticity. These qualities 
are further assured in the larger hair by a central marrow or medulla, which 
is composed of loosely packed embryonal corpuscles, f atty and pigment matter, 
and extends through the root of the hair to its point. The hair, after it 
emerges from the skin, has the same structure as the root, minus the root- 
sheaths. 

The color of the hair is due to the granules and diffused pigment which 
is deposited in and between the scales of both the cortex and marrow of the 
hair. The degree of pigmentation usually corresponds with that of other 
parts of the skin. It varies widely in different races and individuals, and, to 
some extent, in the same person, under changed states of nutrition, from 
sudden or slowly acting influences on the trophic nerves. Blond and grav 
hairs contain no pigment granules. Hairs are found everywhere in the 
skin, except upon the soles of the feet, palms of the hands, the last phalanges 
of the fingers and toes and the penis. They are sometimes divided into three 
classes: The fine, downy, or lanugo hairs, found upon the general surface; the 
long and soft hair of the scalp, beard, axilla? and pubes; and the short hairs, 
as found upon the eyebrows and eyelids. 

Each hair, normally, has a limited existence, and is shed by a process of 
separation, which takes places about the bulb accompanied by a contraction 
of the hair follicles at this point. The new hair is regenerated from the 



ANATOMY 11 

inner root-sheath about the papilla, and, as it grows, pushes the dead hair before 
it until it is shed or accidentally removed by traction upon it from without. 

It will be seen that the hair is not only derived from the epidermis, but 
that its production is a process of cornification under conditions which form a 
cornified cylinder, which is projected from the cutaneous surface and is very 
analogous to the cornification which takes place in the epidermis itself. 

The Nails. — The nails are concavo-convex, horn-like, elastic plates firmlv 
imbedded in the 6kin of the dorsum of the last phalanges of the fingers and 
toes; fully exposed on their upper surface and terminating in free border. 
which, if uncut, extends beyond the ends of the fi] The nail 

consists of horny epithelia like the corneous layer of the epidermis, only more 
dense in structure. According to Bowen the nail is a modified growth of the 
innermost row6 of cells of the corneous layer, or. as it is frequently called, the 
stratum lucidum. About the third month of festal life two or tlm > 
epithelia from the mucous layer appear at the site of the future nail-root. 
In the fourth month one or two additional rows of epithelia are pro; 

\- the! mature they are gradually forced forward 

between the rete mucosum and the horny layer of that part of the epidi 
which is to be the nail-bed. By the '.h month the nail 

- way through thi layer, and at intra-nterine 

life is usually well d( 

The wiil-fu -kin in which rests the border of the nail not 

bj the pi iwth. !• continuous at the root of 

tin- nail with the nail-n • with the nail-bed. 

The ads from the floor of 

ail-fold at tl border of the 

lunul • bt-COlored part of the 

nail. The derma of the matr which is 

blended with the : th and rises aboTe into 

mIIh parallel with tl; tpilhe 

ward, and ai it the lunula. 

On the papilhe and in the fm the mm 

■ ie horn] 
nail. According bo ' or part of the matrix 

produces the horn; plates of the surfae middle of the matrix, 

iddle of the nail, and rior part of the lunula, the andermoet part 

of the nail. 

The niiil-li- 1{, or the I i hich supports the nail, as it is pue 

forward from the matrix. from the am. -rior border of the lat: 

the bt of the free part of the nail. I- subcutaneous 

steam beneath, high i papilla? from 

"rium running the full length of the nail-bed. and over the papilhe and 

their interspaces prick of the mucous layer so arranged as to pr 

a grooved appearance of the upper surface of the nail-bed. Into these grooves 

ding ridges on the m nail lit. thus giving firm 

attachment nf the nail to the nail-bed. 



12 ANATOMY 

At the junction of the nail-bed and the free border of the nail the granular 
and corneous layers are united again with the mucous layer, so that at this 
point the nail rides over a complete epidermis instead of over the cells of the 
mucous layer in the nail-bed. This junction can be seen through the nail, 
as a yellowish-white line just behind the free border of the nail if the ball of 
the finger is pressed against a hard substance. 

The matrix and nail-bed are freely supplied with arteries and veins which, 
according to Hoyer, have direct communication without intervening capil- 
laries. This provision permits a temporary stoppage of circulation in these 
exposed parts without liability of injury to them. The transparency of the 
nail over the nail-bed allows the color of the blood to show through the nail, 
while the opacity of the visible part of the nail over the nail matrix (the 
lunula), due to the changes in the superficial cells of the mucous layer under- 
going cornifieation, entirely shuts off from sight the color of the blood in the 
vessels of the matrix. 

Blood-vessels. — The skin is supplied with abundant and freely distrib- 
uted blood-vessels in all its parts, except the epidermis. The arterial supply 
is derived from subcutaneous branches which pass through the fascia and, by 
division and subdivision, form, as Tomsa has shown, three separate vascular 
districts. The deepest supply the subcutaneous fat with numerous capillaries 
in a net-like arrangement inside and between the fat lobules (A, Fig. 1). 
The middle district sends off arterioles to form a capillary plexus for the coil 
glands (B, Fig. 1). The capillaries supply the tubule and end in small 
veins, one of which passes upward with the duct of the sweat gland and anas- 
tomoses with the veins of the papillary region. The third or upper district 
is supplied from an ascending artery (F, Fig. 1), which sends off branches 
to form capillaries for the hair follicles, the sebaceous glands and the papillae. 
Each papilla is furnished with one or two capillary loops. The papilla of the 
hair has its own arteriole and capillary similar to those of the papillae of the 
corium. The capillaries of the papillary layer anastomose freely with those 
of the upper part of the hair follicles from which loops pass to supply the 
sebaceous glands. 

The most superficial veins of the skin are derived from the capillaries of 
the papillae (V, Fig. 1) and form narrow meshes, which, together with the 
deeper and circular veins, form venous branches which anastomose with 
branches from the hair follicles and sebaceous glands. These unite into larger 
vessels, and with the veins from the coil glands and fat lobules merge into the 
venous sinuses which end in the subcutaneous veins. 

Vaso-motor nerves accompany the capillaries of the skin everywhere. 
Under their domination the capillary circulation is largely concerned in 
the physiological functions of the skin as well as in pathological changes in 
its functions or tissues. A sudden dilatation of these vessels produces the 
common phenomenon of blushing; and a sudden contraction the equallv 
marked blanching of the surface. 

Lymphatics. — The lymphatic vessels proper are relatively few, and com- 



ANATOMY 13 

monly are appendages to the blood-vessels, their contents flowing from the 
papillary portion of the coriura inward to communicate directly with the 
subcutaneous blood-vessels. There are, however, according to Unna, juice 
spaces or lymphatic channels in every part of the skin which usually do not 
have independent walls nor absolutely free out-flow of lymph into the lym- 
phatic vessels. These lymph channels are uniformly present in the papillae 
of the eorium and converge near the middle of the base where a lymphatic 

-el usually begins. From the apices of the papilla? lymph flows into the 
mucous layer of the epidermis in all directions through the inter-epithelial 
spaces and between the prickle threads which unite the epithelia. 

The return flow of lymph to the eorium occurs slowly by way of the inter- 
papillary di - of the epidermis through minute openings, or, possibly, 
through the ducts of the sweat glands which emerge at these points. Juice 
spaces similar to those of the epidermis exist in the hair follicles, in the 
sebaceous glands, and in the ducts of the coil glands, and form a sheath-like 
ig about the connective tissue bundles, the oblique muscles and the 
fat-cells. The course of the lymph in the eoriun rly downward to the 
lymphatic vessels. The passage of lymph from the spaces of the coil glands 
and fat tissue is by slow filtration into the neighboring veins or lymphatic 
vessels. This an I peculiarity facilitat nnation of subcutaneous 
fat. No lymphatic Tea* md either in fat or in subcu- 
ie free from fat. 
:\is. — The skin is abundantly supplied with medullary and non- 
medullary nervi of branchei from the cerebral and spinal oei 
which enter the .-kin and form horizontal bundle! QtaneoUS tissue. 
tai upwards with th<' blood-vessels through the eorium, 
and divide into QUI ons in i ary layer, some assum- 
ing a horisontal position t" the surface, and an- disposed about the sui>- 
papillary vessels and capillaries of the papilla?. Other short narv< up 

lidermis into non-medullated fibrills?, which send <>tr nume 
branches, of which a smaller number end with free extremities in the com 
ti\. or "ii the endothi I a larger Dumber penetrate 

into the epidern i n the basal cells. The nerves of the epidermis, after 

many divisions, and. possibly, reunions i" form plexus.-; (1'nna) in the intcr- 
capillar . finally send o)T from different points tine threads for each 

prickle cell, as far as the granular layer. These Derve-threada penetrate the 
cell protoplasm and terminate in minute bulbs <>n or about the audi 
Borne branches end in bulbs between the epithelia, hut without any regularity 
of distribution. Non*fMdvUary nerve fibres are also supplied to the cells of 
the hair-sheath and the ducts of the coil glandi ■ding to Crause all 

rve filaments ultimately terminate without medullary sul.stance 
ami in minute enlargements. A- these nerve terminations are found in 
largest part, and uniformly in the cells of the epidermis up to the corneous 
layer, they would appear to he the transmitt Deral sensation. 

The muscles of the skin and the sheaths of blood- ire supplied 



14 ANATOMY 

with motor-nerve fibres, while to the secreting structures and protoplasmic 
formations trophic nerves are distributed. Eegarding the latter little, how- 
ever, is positively known. 

Medullary nerves of the skin terminate in the Pacinian and tactile corpus- 
cles, and according to Eobinson, some branches pass into the papillae, then 
change their direction downward to the deeper part of the corium, to reascend 
to the papillary region to adjacent papillae. Similar loops are given off from 
the nerve-bundles before they reach the papillary layer. 

Pacinian corpuscles or corpuscles of Vater are small oval bodies mostly 
situated in the subcutaneous tissue, in some parts visible to the naked eye and 
measuring two or more millimetres in width by three or more in length. 
Each corpuscle consists of capsules made up of a large number of concentric- 
ally placed hyalin and connective tissue lamellae, resembling the outer struc- 
ture of an onion, and enclosing a central space or core of transparent proto- 
plasmic material, in the centre of which is a single mcdiillary nerve fibre. 
The medullary sheath of the nerve is lost in the tissue of the capsules before 
it reaches the central space. In the central space the nerve-fibre continues to 
the distal end and there divides into two or more club-shaped enlargements. 
Eanvier claims that after supplying one corpuscle the nerve may pass on to 
penetrate a second or even a third; and Eobinson says the nerve may form 
a loop or loops, and then pass out at one or the other pole of the corpuscle. 
In such cases the nerve regains its sheath from the capsules at the point of 
exit. 

The tactile corpuscles; corpuscles of Meissner or of Wagner (X, Fig. 1), 
are found in the papillae of the corium, usually filling the greater part of the 
non-vascular papillae. They are roundish or oval bodies of about one-tenth 
the size of the Pacinian corpuscle. They consist of connective tissue cells 
with small nuclei interwoven into vertical or spiral rolls, which go to form one 
to three lobules, and are surrounded by a denser connective tissue or capsule. 
Each corpuscle is penetrated at one extremity by one or two medullary nerves, 
which lose their myeline sheaths in the fibrous substance of the corpuscle. A 
nerve branch passes to each lobule where it divides into delicate fibrillae, which 
ramify between the connective tissue cells, anastomose with each other and 
terminate in slight enlargements; or, according to Eobinson, they may pene- 
trate the capsule at the distal extremity and emerge therefrom as one or more 
efferent nerves. Delicate nerve-threads encircle the corpuscle and pass up- 
wards with other nerves to the rete. The afferent nerve of a corpuscle may 
be supplied from an adjacent papilla, or one nerve may supplv two or nioro 
corpuscles. 

Muscles. — The voluntary muscles of the shin are chiefly limited to the 
face and neck. They consist of striated muscle fibres, which pass obliquely 
from the subcutaneous tissue into the corium. Their action under the influ- 
ence of the emotions or the will aids in giving various expressions to the 
features. In some of the lower animals analogous muscles are large and 
abundantly distributed. 



ANATOMY 16 

Involuntary muscles of the skin are found in the eorium occupying hori- 
zontal and oblique positions in relation to the surface. The horizontal layers 
are found chiefly in the scrotum, penis, areola and nipple of the breast, and 
the eyelids. The contraction of these muscles forces the skin into folds and 
changes its external appearance. 

The oblique muscles are found in nearly all parts of the eorium, either 
as minute fasciculi, without attachment to the hair follicles, or as more dis- 
tinct muscular bundles with multiple attachment to several adjacent hair 
follicles below, and a similar attachment to the papillary layer above, and 
known as the erectores pilorum. 

The erectores not only have fixed points of attachment to the papillary 
layer of the eorium and fixed points of insertion into several hair follicles at 

of the hair papillae; but by means oi fibres, 

which surround and mingle with them throughout their length and at their 

to the elastic- 
work oi the eorium. Their dir- oblique. The direction of the 
hair ■ a less oblique angle, a powerful isclea 
pulls the hair of the lower animal - 

•i in a mark' portant which 

follou i of the oblique "f the eorium are the 

expulsion of sebum bj -sion of the ■ebsceoui glands, a l e s sene d circu- 

lation of blood in the papillary layer. Slid miration from the 

a of the upper | the eorium. The compressi<.' 

upon the skin in 1 ••* produces an sppsn d* the 

surface, or cuds a ral effect is to prevent loss 

of bodily tern] om of the oblique in 

of the sk . ■ rnal cold stimulates their 

m. 
r of the -kin d< (piantit 

-sels of • in, snd to tl at "f pig 

present in the layers of tl '*hat by 

to the heat of the sun ither diffi 

In the whib in ■■ usually 

• and limited ithelia of the 

epidermis. Deep* 'is of t! e (as the 

scrotum and general in te gu m e n t of the 

er or di 
in the prickle cells and their DUcleL In the Di tation SI 

to the granular layer, and a dark coloration <>f the skin results. There is 
pigmentation "ft!' -. and only 

in abnormal conditions is it found in I m. 



16 PHYSIOLOGY 



PHYSIOLOGY 

The functions of the skin have been already mentioned, and the general 
office of the skin as a protective covering of the other tissues, etc., briefly stated. 
The active functions of the skin are of much importance in relation to 
many of its diseases. Secretions and excretions of the skin are furnished by 
the sudoriparous and sebaceous glands. 

Sweat. — The sudoriparous coil glands produce perspiration or sweat, 
which is ordinarily rapidly evaporated from the surface in the form of vapor 
or insensible perspiration. The quantity of vapor of water given off by the 
skin is nearly double that eliminated by the lungs. The quantity varies with 
the season, occupation, etc., from one to two pounds daily. If evaporation 
from the surface is retarded, or the excretion markedly increased, sweat 
accumulates on the surface in drops, sensible perspiration. The secretion of 
sweat is largely under the control of the perspiratory nerve centres, located 
probably in the spinal cord and medulla. These centres may be directly or 
renexly stimulated, and act, through the local nerve fibres, directly on the 
epithelia of the coil glands. Sweat is increased by heat, changes in the blood, 
by certain drugs, such as camphor, pilocarpine, and toxic doses of strychnine, 
etc. Pilocarpine and some other alkaloids are believed to stimulate the secre- 
tion of sweat by acting directly on the peripheral nerves. The secretion of 
sweat is diminished by cooling the skin, by suspension of the blood supply, 
and by such drugs as atropine, morphine, etc. The normal increase of per- 
spiration is attended with increased activity of the local circulation, but in 
abnormal conditions the perspiratory nerves may act independently of the 
vaso-motor system, and a free secretion of sweat occur when the skin is pale and 
cold. The normal perspiration is composed of about ninety-nine per cent, 
of water and one per cent, of organic and inorganic constituents. It is saltish 
to the taste, alkaline or neutral in reaction, and lias a characteristic odor. 
The organic matter consists of urea, fat aud various fatty acids. The quantity 
of urea in the sweat is small and varies but little in health, but in pathological 
states of the kidneys, with suppression of excretion of urea by those organs, 
it may be enormously increased. The kidneys and skin hold compensating 
relations normally to each other; the lessened perspiration from the skin in 
cool weather is compensated for by an increase of urinary fluid, and vice 
in warm weather. The chief inorganic solids of the sweat are the chlorides 
of sodium and potassium and some phosphates and carbonates. The sweat 
aids in removing effete material from the system, in preventing, by surface 
evaporation, a rise in bodily temperature, and helps to lubricate and protect 
the cutaneous surface. 

Sebum. — The secretion of the sebaceous glands is a semi-fluid fat, which is 
insensibly discharged from the sebaceous glands upon the skin, and varies 



PHYSIOLOGY 1< 

considerably in consistency and quantity within the limits of health. Its 
chemical constituents have been found to be water, fats, saponified fats, caseine, 
albumin, cholesterine and a small proportion of the salts of sodium. 

The function of the sebum is mainly preservative. It protects, in a 
measure, the surface of the skin from external infection, from the softening 
effect of long-continued moisture, and, at the mucous outlets, from the con- 
tact of irritating excretions. It may prevent too rapid evaporation from the 
cutaneous surface and consequent undue loss of heat. It probably contributes 
to the nutrition of the hair, and presei Eternal surface Unlike the 

secretion of swt tied in the production of sebum. 

1 1 \ : B —A variation of bodily temperature of ten degrees 

from normal, either above 03 apatible with continued life, yet 

vide atmospheric variations are endur- rat harm and with but 

slight, if any, change in n important part in 

ni;i tture by n-gulating loss of heat. It is 

ed that from seventy .1 loss of bodily I 

- a 

\vh< I heat. When the surface is cooled, the 

rant of blood sent to the skin is greatly diminished by shrinking of the 

«sels throng] r muscular by 

a time increased teni -vies 

as, and thereby diminishes the discharge of 

loss of a minimum require.: 

normal internal b • or of heat 

phyi relax the the 

: the skin. A lai 
tin- Mij.erlicies of the skin ai and loss of heat takes p] 

liation from II oat-loss is aided 

IT, and i • air. 

naturally In! epi- 

''' rl " is - Wlt - Ldoriparons 

docti U --ous follicles, ofi n to absorption by 

fly 

'" ' ipidly. The absorption throu 

the epidermii ■ sontewl , ; t j, 

hoi, chloroform j„ 

B lb I Qg :.:• In this wav many 

""'' i into i ; , and exert their 

only in grm than «i phthol, ml 

I in this manner. Arsenic 
and up by the skiii in sufficient quantity to Cfl 

Gases and volatile vapors • through the skin into the blood. 

nd nitrogen are absorbed by the skin is not known. 

Car l is e l iminated by th rant of two or three drachi 

{,ail - 8 BO-calll ratory fund 



18 PHYSIOLOGY 

of the skin, which Scharling, at one time, estimated to be about one-fiftieth 
of the respiratory work of the lungs. 

It is altogether probable that all substances which are absorbed by the 
skin pass through the outer parts of the epidermis (sometimes aided by 
friction), by way of the gland ducts and hair follicles, whose walls are only 
lined with a single layer of epithelia, and thus present a comparatively slight 
barrier to absorption. Mercury in ointment is absorbed in this way in the 
form of vapor, or after being dissolved by the acid secretions of the skin. 
Watery vapor is readily absorbed by the skin from the surrounding air, and 
water in contact with the surface may enter the epidermis in considerable 
quantity, by soakage, without actual absorption. Bacteria may be absorbed 
by the skin. Furuncles have been produced by rubbing into the sound skin 
cultures of the staphylococcus pyogenes aurens. According to Wasniuth, 
bacteria do not enter the skin by the sweat or sebaceous passages, but by way 
of the opening between the hair-shaft and the sheath. 

Sensation". — An important function of the skin is that of general sensa- 
tion, and the special sensations of touch and temperature. General sensation 
is provided for every part of the skin, the thinnest portions of the skin being 
most sensitive, and the thickest portions the least sensitive. Ordinary contact 
becomes painful, if applied directly to the coriuin. The acuteness of tactile 
sensation depends on the distribution of the sensitive papillae of the corium. 
Where these are abundant, as in the skin of the end of the third finger, sense 
of touch exists in a high degree. Webber found, by experiment, that at these 
parts two distinct sensations of touch could be felt, only one twenty-fourth of 
an inch apart. The middle of the thigh and forearm appear to be the least 
endowed with the sense of touch, the distance at which two points of contact 
can be distinguished in these regions being upwards of two inches apart. 

The sense of touch not only makes known the size, shape and other 
properties of bodies, but with it may be felt the varieties of pain and differ- 
ences of temperature. Goldscheider believes there are two kinds of sensitive 
nerves of touch. The office of the tactile corpuscle, in the light of later investi- 
gations, appears to be to give greater mechanical protection to the nerve ter- 
minations. The quality of touch can be educated to a surprising degree. 
This is well illustrated in the blind, who, by their delicacy and expertness 
of touch, seem almost to supply a substitute for the loss of vision. The distri- 
bution of temperature sensation is very like that of common sensation, and 
varies in different parts of the skin; but is not modified by the relative thick- 
ness of the skin to the same extent as general sensation. 

Formerly, temperature perception was thought to be a variety of general 
sensation. The experiments of Blix and Goldscheider not only tend to 
disprove this, but seem to show that there is a separate nerve mechanism 
for cold, heat and pressure. Experimenting independently of each other, 
they found that the same irritant produced on some parts of the skin a sense 
of cold, on others heat, and on yet others only ordinary sense of pressure. 
It is well known that in some diseases attended with paralysis of ordinary 



SYMPTOMATOLOGY 19 

-ation, sensitiveness to heat and cold may remain intact. The degree of 
temperature felt depends, in great measure, on the extent of surface exposed. 
One finger, for instance, can be comfortably borne in hot water, which would 
become painfully hot to the whole submerged hand. The tip of the tongue, 
the fingers and face are most sensitive to temperature change. From one-half 
to one degree variation can be appreciated by those parts. 



SYMPTOMATOLOGY 

Tin. manifestations of disease, by which it- ized, are 

known as symptoms. One class of symptoms are felt only by the patient, as 
disturbances of sensation, and are 1. - subjective symptoms. Another 

ay be observed I md person, with or without the aid of the 

patient, and are known as o The relative importance of 

-•■ tun i obably more nearly equal in ■ of 

the skin than in an 'it of medicine. 

may he limited to tin- .-kin ;> moid 

;m\ other part of the I" atly the lathological relation- 
skin disease with ther functional or Such 
itionship itaneoui E cause and effect Most 
often the skin . internal distal a local or 
:. It i: 1. therefore, that usually the .-\mp- 

aplcte anless it ineludes all tin- symptom! 
a\ at the tin • itomy, .-.- -kin 

If. Study and anal; 

and therapeul 

Sir., ii . n\i -\mi-i. t. may lie of great elinieal 

"I'u an. <■. The] in intei !"rom t! 

of heat of a mild erythema to \l.<- m . malignant 

lional condition, a- the 

so-called "boi liilis; th< D furuncles', or r 

ma - in many ir f prurii 

of all sul.j«( tivr symptoms of the .-km. It may l»' present in modified form, 

as a i v or less pronounced Ktiglingj ,-j. ctsm »n), 

tickling, or a- a □ any degree up to an intolerable sensation, 

which cannot be borne without n - often occurs in prurigo 

and ec/ema. Total of pruritus aids greatly in d . syphi- 

litic from noii-syphilitii whicli objectively have a cL 

Not infrequently t! •> absence of subjective symptoms in the skin in 

benign cutai oe, for instance, they may he slight or want- 

of the digestive organs, 
the genito-urinaj the upper respiratory tract may be often found; 

or. again, a i i with debility, sensations of weakness, languor, headache, 



20 



SYMPTOMATOLOGY 



etc., may form a group of subjective symptoms. The sharp neuralgic pains 
which commonly precede an outbreak of zoster are characteristic of that 
affection. 

The chief value of subjective symptoms, whether in or apart from the skin, 
depends on their nature, location and behavior under varied influences, acting 
from without or from within the body. The nature of sensation, whether a 
burning, smarting, stinging, gnawing, aching, shooting, etc.; the location, 
whether limited to one part, a few parts, or generalized; behavior, whether 
unaffected, relieved, or aggravated by time of day, cold, heat, water, clothing, 
rest, exercise, eating, drinking, sleep, mental or physical occupation, etc.; 
all these give character to subjective symptoms and establish their value, 
especially in the therapeutic domain. No one, who has not studied the char- 
acteristics of subjective symptoms can comprehend that, contrary to the 
opinion of many dermatologists, subjective symptoms are nearly, if not quite, 
equal in importance to objective sjonptoms. 

Objective symptoms comprise pathological changes, which occur in the 
skin and are also known as primary and secondary lesions. These distinct 
lesions are few in number, and may be, in a degree, successive stages in 
pathological evolution; yet, in differences of grouping, modes of occurrence 
and other features, they form the many varieties of cutaneous disease. So- 
called primary lesions are not always first in order of occurrence, but may 
be consecutive to other elementary lesions. Again, some lesions are common 
to several diseases. One or more lesions presenting certain features and with 
or without the presence of certain subjective symptoms distinguish each disease 
and form the basis of dermatology. A knowledge of lesions is, therefore, 
most essential. They are grouped as follows : 



Primary Lesions. 

1. Macules, 

2. Papules, 

3. Wheals, 

4. Tubercles, 

5. Tumors, 

6. Vesicles, 

7. Bulla?, 

8. Pustules, 

9. Scales. 



Secondary Lesions. 

10. Crusts, 

11. Excoriations, 

12. Fissures, 

13. Ulcerations, 

14. Cicatrices, 

15. Unclassified. 



PRIMARY LESIONS 



Mabules (spots, stains, macula?) are changes of color of the skin 
with little or no elevation, due to various causes, and are of various 
sizes, shapes and tints. In size they vary from a pin's point to patches of 
several square inches. In shape they may be irregular, ovoid or circular, bur. 
most often they have a roundish outline. The}' vary in color from a verv 



SYMPTOMATOLOGY 21 

light red to a very dark brown, and their duration may be short or long. 
Their color may or may not temporarily disappear on pressure, and they 
may or may not be attended with subjective symptoms: usually the latter 
are wanting. Macules may be due to hypenemia, to extravasations of blood, 
to dilatation of blood-vessels, or to changes in the pigmentation of the skin, 
and are designated as follows: 

Erythema or roseola are the terms used to denote acute hyperemia of the 
skin. Their color is red, if due to arterial i i: bluish-red. if due to 

HOU usion; and they alu ;ipear on pr> - If a fluid exu- 

dation from the blood-vessels into the cells of the skin takes place, there is 
some swelling of the skin, and occasionally a alight elevation of the surf a 

m escape of the coloring matter of the blood occurs with the 

exudation, ami gives a yellowish shade to the patches. Brytki urs 

either in in or is more <>r less generally diffused 

tin' surface. It forms a or halo about an inflamed area 

of skin. Roseola occurs in round or oval-shape'! oring thi of 

>-re, rarely exceeding the -ize. 

Dii of blood into the superficial tissues of 

i. which reddiah-purple color 

at : n ging to various shades of so-ca! k and blue," as absorp- 

1 ii partial ran ruction 

aes only the i >f the bl< es and Bhows in yellow- 

ish- When the mall and round, they are called 

P< UckUl ; V, 

I'urpur primary in occurra indary to inflammatory 

il dilatation of the 
m. and U !ar acquired ehai 

of the hlood-vessels. 

DOrmal of the skin may be due 

to increase or loss of pigment I of pigment, 

I vitiligo of diminution of pig may lie perma- 

ij< -lit "i- of -hort <lurati-.n ; o . as in i uired. as in free' 

Difl . a* in jaundice, malarial melanof are not 

called i .tion of I Pigmentary macules are some- 

times secondary to other seaaes, a.- liter acne, lii 

planus, urticar I .in with rntanis or I 

may be followed by in pigment may attend or 

follow other cl an, as the light spots in scleroderma, cica- 

trices, • 

IV papuhe, pimples) are small solid elevations of the skin. 

Papules an- never large, bul B from a point barely discernible 

to aighl to s split pea. In Bhape they may be round or angnlar at the hase; 
more or less conical, flat, or ombilicated at the summit. Papules never con- 
tain fluid, hut they may be trs ' into moist lesions, which dry into 
crusts or degenerate into ulcers, followed by They may be some shade 






22 SYMPTOMATOLOGY 

of red, yellow, blackish, or whitish in color; of short or long duration, or 
permanent; and they may be inflammatory or non-inflammatory in origin. 
Besides the size, form, color, duration, etc., of papules, their concomitant 
conditions, if present, should be carefully noted, such as fever, itching, or 
other subjective sensations, the extent of infiltration of adjacent skin and other 
lesions. 

The anatomical seat of papules varies. The inflammatory arise from an 
exudation into a few of the papilla? of the corium, with swelling of the supra- 
imposed cells of the mucous layer of the epidermis; or they may involve the 
deeper parts of the corium also. The non-inflammatory may be due to small 
masses of horny scales about the hair follicles, as in keratosis pilaris, or 
accumulation of sebum in the outlets of the sebaceous glands, as in comedo 
and milium ; or to a tonic contraction of the erectorpili muscles, as is claimed 
by Auspitz in prurigo. Papules which have been torn by scratching or 
rubbing often present at their apex a minute blood point or crust. 

Wheals (pomphi, urticae) are solid, circumscribed, irregular eleva- 
tions of the skin, usually pinkish-white in color, and characterized by 
rapidity of efflorescence, short duration and frequency of recurrence. 

Wheals vary in size from a pin's head to an egg. They are firm to the 
touch, usually flatly convex or hemispherical; but may occur in circles, bands, 
gyrations, or coalesce and form irregular patches. Generally, they are of a 
light pink color, with a whitish centre, and sometimes a pink, or again a whit- 
ish anaemic areola. 

Wheals in few or large number, in crops or successively, are evolved in a 
few minutes, or even in the fraction of a minute, and disappear as rapidly 
at the end of a few hours or days. They are rarely persistent. They may 
become purple from hemorrhage into them, or they may be converted into 
bullae; and occasionally they leave behind pigmented macules or other lesions. 
They are always accompanied with marked sensation of stinging, tingling 
or itching. Wheals originate from angio-neurotic irritation, which causes 
a sudden exudation of serum from the blood-vessels into the papilla? of the 
corium. Contraction of the vessels produces an anaemic centre, and, at the 
same time, prevents resorption. Eelaxation of the capillaries is followed by 
rapid absorption. Wheals are diagnostic of urticaria. They may be caused, 
however, by local influences, such as the stings of insects, contact with the 
ordinary nettle, etc., and they may often be observed after hypodermic injec- 
tions of watery solutions. 

Tubercles ( tubercular, nodules) are solid, circumscribed, cellular in- 
filtrations of the deeper parts of the skin, more or less elevated above 
the surface, with well-defined borders and conical or flat tops, and vary 
in size from a split pea to a cherry. Tubercles have been considered to 
correspond to papules in color, shape, etc., or in all ways except size. They 
differ, however, from papules, not only in size, but in their origin in a deeper 
part of the skin, slower course, and less tendency to spontaneous resolution. 
From their deeper seat they may project upon the skin in a less degree than 



SYMPTOMATOLOGY 23 

the papule; they may be fixed in the skin by a broad base, or they mav 
have a narrow attachment and largely protrude upon the surface. Tubercles 
sometimes become diffuse from peripheral extension and coalescence, and 
may involve the subcutaneous tissues as well as the skin. Ulcerating or 
degenerating tubercles lead to considerable destruction of tissue and conse- 
quent scarring of the skin when repair ensues. The word "tubercle," designat- 
ing a form of lesion, should not be confused with the pathological condition 
known as ''tuberculosis"; or, on the other hand, with growths usually of 
larger size and classed as "tumoi 

Tumors (tumores, phymata) are solid, or solid and cystic new growths, 
of any size from a pea upwards; benign or malignant, of variable shape, 
consistency and color. 

Tumors ma] ate from any pari "f the skin. it- ap -sels 

or nerves; one or more parts in a single lesion. They may arise from new 
formations situated within and beneath the derma, movable or firmly attached 
to the pan- beneath, or I ikin, and. if t<> the latter, raising its surf. 

or i "in it in a rariable • . may become pedunculated 

or even pendnli it may not be attended with subjective symp- 

toms. Tumors occur in fibroma, carcinot 

tike) are elevations of the horny layer of the epider- 
mis, from a mustard seed to a coffee bean in size, containing a serous 
fluid exudate from the superficial or deep parts of the skin. Vesicles 
are usually of inflamn .: they may be, however. 

non-innammatoi the chief feature of an 

eruption and seated in the -km. U in I they may be secondary and 

rnal to othi at the ■ i papule no. Their fluid 

may be —purulent from the of pus, or -anions and 

•ero-sanguineous from admixture of blood. They are generally tense: round- 
ish at the base, if d and convex at the top, or pitied, as in varicella, 
ftaccid from collapse upon tl often formed in groups, or 
I patches; are usually single chambered, but may be 

multiloeular. a.- in mattpOX. 

\. of comparatively short duration; terminate by spontaneous 

or accidental rupture and discharge of fluid upon the adjacent surface; or 
they may dry in' may also be transformed into bulls by increase 

of size, or into pustules, or become the teai of ulceration. An eruption of 
inflammatory vesicles is usually attended with subjective sensations of itch- 
ing, burning or stinging. 

Hi. Kits (bullae, blisters) are vesicles of a pea size, or larger, and may 
be formed by a confluence of vesicles. Like they are most often 

formed in the deep and middle layers of the epidermis; may contain serum. 
pus. blood or lymph; may be tense or flaccid : and mav terminate in a similar 
manner as by rupture, desiccation or ulceration. They differ from 

vesicles in their having stronger roof-walla, less tendency to spontaneous 
rupture, longer duration, their more frequent seat in apparently normal skin, 



24 SYMPTOMATOLOGY 

greater freedom from subjective sensations, and in indicating a graver sys- 
temic condition. 

In shape, bullae may be oval, hemispherical, erescentic, round or irregular 
from coalescence of a number of lesions. Single bulla vary in size from a pea 
to a goose egg ; but when confluent, they may sometimes form enormous lesions. 
Blebs are a diagnostic symptom in pemphigus, hydroa, herpes iris and pom- 
pholyx; and may appear in the course of cutaneous syphilis, erysipelas, urti- 
caria, exudative erythema, and exceptionally in almost any inflammation of 
the skin. 

Pustules (pustulae) are circumscribed elevations of the skin, of in- 
flammatory origin, containing pus and pus cocci, and varying in size from 
a millet seed to a hazel nut. 

Pustules may arise as such, but most frequently originate from vesicles 
or papules. Transitional forms are known as vesico-pustules or papulo-pus- 
tules. They may be roundish, globoid, convex, irregular, pointed, flat or 
umbilicated in shape; in color, yellowish or blood-stained, surrounded by the 
normal-hued skin, or by an areola; sometimes with induration, as in boils; 
or an indurated base, as in ecthyma. They may be situated around the 
sebaceous glands, as in acne; around the hair follicles, as in sycosis; deep in 
the corium, as in furuncles; or involve only the papillae and epidermis. The 
largest proportion of pustules arise in the papillary layer; and, if the destruc- 
tive process extend to several papillae or to the deeper parts of the skin, a scar 
may result. Epidermic pustules heal without cicatrix. 

The evolution of pustules is generally rapid; they usually rupture and 
form firm, yellowish, greenish or brownish crusts ; or dry without rupture into 
somewhat lighter colored crusts. They are frequently attended with soreness 
or tenderness, but rarely with any degree of itching. 

The pathological process in variola is different from other pustulous affec- 
tions, in that the exudation occurs within the cells instead of within a newly 
formed cavity. The distended cell-walls form a multilocular pock or pustule, 
which cannot be opened by a single puncture. 

Scales (squama) are dry epithelial matter exfoliated from the sur- 
face of the skin in appreciable quantity, as the result of an over-produc- 
tion of epidermic cells, generally without exudation. 

Scales are usually inflammatory in origin. They may be primary and 
characteristic, as in psoriasis; or secondary, as in scarlatina and eczema. When 
they are thrown off in fine, small scales, they are called branny or f urfuraceous ; 
and lamellae, when as large as the finger nail or larger. Thev mar be scantv 
and firmly attached; or they may be abundant and freely shed; they may be 
dry or fatty, white, pearly white, or yellowish. They may occur in single 
layers, or massed together in variable degree. The so-called scales of sebor- 
rhcea are made up of dried sebum and epithelial cells. Scales occur commonly 
in such diseases as squamous eczema, psoriasis, ichthyosis, squamous syphilide, 
ringworm and favus. 



SYMPTOMATOLOGY 25 



SECONDARY LESIONS 

Crusts (crusts) are the remains of effete products of disease, more 
or less changed by desiccation. 

Crusts usually cons; rum, pus, or blood, intermingled with epithe- 

lium, and are seconda: 16 inflammation of subjacent parts. They may, 

it of fat ami epithelium, or of fungus growths, 

as in fains. They vary in color, with the nature of tbe exudation from which 
!. from the light yellow of serous products, the green- 
i.-h 01 i-vellow of i mulations, to the brownish or blackish hue 

due to the presence of blood. If the i ■ free and thin, they must 

Boon I n off ; if thick, the] n layers and raised above 

of the skin. They may be .-mall <>r large; firm or friable; thick or 
I or loot! skin. i>r a superficial 

or deep ulcer. In outline, tl • rally follow the lesions which produce 

: hut may l»e disposed among other D a way to obscure their 

lary or > . syphilis, 

I many o tnmon afl 

ire superficial solutions of continuity usually due to 
mechanical injury, and varying in size, shape, and depth with the nature 
and degree of the force which produced them. 

fly in dis.-a- ed with itching of the skin, 

and oommonlj result from k ; but may In- caused 

by ruhhin 

• •s. When due to tearing 
with the found only on ble to the lii 

•i pruritus, or be secondary in 

papular atfe< tions, Linear 

in phthiri with a superficial re a: and if due 

per injury, exud -. which dries into brownish crusts. 

•nations are found in 

ire linear solutions of continuity involving the 
epidermis and corium, due to either injury or disease. They occur chiefly 

to frequent movement, or inelastic, 

■ ned or hard. Tim- mid from disease in the normal lines 

of the -kin, in th - of the join- d the 

I the body, and on the palms and sol, -. M..-t 
fissures an lent to the infiltration and thickening 

of the skin produced by that d or in syphilis, dermatitis, 

ty, or from any factor which in< on the skin, which 

has been rendered inelastic. If they involvi irium they are likely to lie 

painful on movement, may bleed <a-il to -"in.' secretion. From 

their nature and situation the} oft^n complicate greatly tin in which 

they appear. 



26 SYMPTOMATOLOGY 

Ulcers (ulceration, ulcera) are losses of substance of the superficial 
and deeper parts of the skin resulting from some morbid process. In size 
ulcers may be small or without definite limit'; in shape they are often round, 
but may be irregular or serpiginous ; the edges may be sharp, rounded, everted 
or undermined; in depth, superficial or deep; their bases, smooth, irregular 
or sloughy; covered with pus or serum, or comparatively clean. The dis- 
charge may be very offensive, or without odor. They are usually quite sensitive 
and bleed easily. If not interfered with, they frequently crust over with 
their dried product. They vary greatly in their course and duration; but 
unless malignant in nature, tend to heal spontaneously and invariably by cica- 
trization. 

Ulcers may be caused by defective nutrition of parts, by infection, by 
suppurative inflammation, and by cellular degeneration of neoplasms. Their 
characteristics relate to their location, shape, size, edge, depth, floors, secretion, 
course, appearance of adjacent skin, and the sensations experienced there- 
from. 

Cicatrices (scars) are new formations, chiefly of fibrous tissue, which 
replace in the process of repair loss of substance extending into the cori- 
um and resulting from either accident or disease. They are covered by an 
epithelial layer; may contain blood-vessels and nerves; but the higher organ- 
ized parts, hair follicles, glands and papillae, are absent. Scars may be smooth, 
shining and pliable; atrophic and commonly result from superficial ulcera- 
tion, or from the involution of cell infiltration or replacement, as in lupus or 
syphilis; they may be hypertrophic from excessive formation of connective 
tissue, as results of deep ulcers or injuries. In such cases they may be 
raised into ridges, elevated above the skin, attached to subjacent tissues, or 
with claw-like projectors in adjacent tissue, as in false keloid. Cicatrices 
are first red in color; they may remain so for some time, become purplish 
or pigmented; but with age they usually become whitish from lessened blood 
supply and previous loss of the pigment layer. Scars may be of considerable 
diagnostic importance. For this purpose their location, shape, color, size, 
surface and mobility should be carefully noted. 

Unclassified lesions include warts, horns, the cup-shaped crusts of 
favus, burrows, etc., which need no description, except in connection with the 
diseases in which the}'' occur. 

GENERAL FEATURES OF LESIONS 

Patches signify the grouping of lesions together in separate areas. 
Patches may be composed of one or several kinds of lesions ; thus there may be 
erythema, papules, vesicles, pustules, occurring singly or in various combina- 
tions, as the erythemato-papular, vesiculo-pustular, etc. The form of the 
patches, their arrangement and the distribution of the individual lesion are 
influenced in a large degree by the direction of the bundles of connective 
tissue fibres (which form the "lines of cleavage" of the skin) and the conse- 



ETIOLOGY -< 

quent vascular distribution to the different parts. The vasomotor centres 
located in the cord, which preside over certain vascular districts, furthermore 
influence the distribution of eruptions. When the lesions of a patch are 
limited in extent and show a well-defined border it is said to be circumscribed ; 
when distributed over a larger and irregular area it is diffuse; when di- 
in circular form or in sections of a circle it is circulate; when in the shape 
of rings, annulate; while the term "iris" is given to lesions having the appear- 
ance of concentric rings; and the terms gyrate or figurate to circles or rings 
which ha seed and faded away at their points of contact with each 

other. A serpiginous patch is one which advances at one edge while clearing 
up at the other or older part; a patch with an abrupt edge is sometimes called 
nnirginate. 

l.i -ions vary in size and shajK*. They are called punctate when occurring 
in dots or prints; miliary, when the 6ize of a mill when the 

size of a drop of water; lenticular, when the size of a pea or bean; and 
nummular, when the size of small coins. When lesions are pointed they are 
atid to be acuminate; when depressed in I when flat. 

Individual lesions when situated apart; confluent, when 

close together or coalescing. 

- a term Died to designate all the lesions and patches collec- 
tively, whi mated upon the skin. When an eruption coven the entire 
cutaneous surface it is said to be universal; when distributed over the whole 
body, with areas of sound skin !>• il : when irregularly scattered 
lurfaoe, disseminatt : when limited lo one or a few regions, "•■i l i:e,t: 
when occurring alike on both lateral halve- <.f the body, symmetrical j when 
limited to one ride of the body, umZaieroi. An eruption is called uniform 
when it c • onlv 01 ultiform, when more than one 
type of prin us are present at the same time. 

M.mi . other qualifying • ployed to describe certain peculiar 

.if in; eruptions, as to regional distribution, cause, clinical appearance, 

Their mean i ar, and therefore no extended explanation 

is ne cessa ry. The term capitis, occurring open the head, usually the scalp; 
itical, produced by an animal oi 

• camples of qualifying words used in describing eruptions. 



ETIOLOGY 

Tii - nf .skin disease arise from many and varied sources, and 

operate from within t ; a (internal) or from without (external). The 

same causative factors do not always produce, directly or indirectly, the same 
><r .-veil like effects upon the skin; while, again, the same disease in different 
may he occasioned by various factors. Specific diseases, however. 
usually correspond t<> specific causes. This varied relationship of many causes 
to disease, together with a want of knowledge regarding the etiology of 



28 ETIOLOGY 

many diseases, stands in the way of the most practical system of grouping 
skin lesions or diseases according to their etiology. Causes themselves may be 
divided for convenience into predisposing and direct. 

Predisposing causes include states of the general system, which have come 
from hereditary transmission; acquired conditions of the fluids and tissues 
of the organism, often manifested by the presence of internal disease of a gen- 
eral or local nature. Cutaneous eruptions occurring under such conditions 
of the system may be incidental or essential symptoms of them, and hence 
are sometimes called symptomatic skin diseases. 

Direct causes are those agencies which act directly upon the skin itself, 
or appear to do so. Diseases produced by direct causes, together with diseases 
which begin in or are confined to the skin, but whose causes escape our obser- 
vation, are termed idiopathic skin diseases. 

It is possible that the same disease at one time may be symptomatic, and 
at another idiopathic. 

General etiojogy of cutaneous disease is, therefore, a principle with a large 
varying relationship, and frequently identical or mingling with the general 
or special causes of other diseases of the system, its organs or parts, which, 
moreover, must be practically learned in connection with individual disease. 
A brief review of the more general predisposing and direct causes will suffice 
here. 

Among the predisposing and general causal agents may be found : 

Age and sex. Life is measured by age, and certain events occurring at 
periods of life are qualified by sex. In the early part of life the more acute 
inflammations and hypertrophy are more apt to occur; in late life, less acute 
inflammation, atrophy and degenerations. Beginning with early infancy, 
strophulus, congenital syphilides, ichthyosis, etc., may appear. Intertrigo, 
impetigo contagiosa and ringworm of the scalp are common to childhood; 
during dentition, erythema, eczema capitis and urticaria are most frequent. 
Acne, seborrhoea and psoriasis seldom develop before puberty. Chromophy- 
tosis, rosacea, lupus erythematosus, etc., are diseases of adult life. Cancer 
and affections due to degenerative changes are rarely seen until middle life 
or in old age. 

Vaccination must now be reckoned as an event in the life of most children. 
While its causal relationship to subsequent disease is not clear, there can be 
little doubt that such relation exists as regards some cases of skin disease. It 
is probable that its influence in such instances is largely to arouse some latent 
tendency in the system, rather than a direct effect. The author has observed 
cases of psoriasis, eczema, furuncle and impetigo which appeared to have 
originated primarily from vaccination. Louis Frank has classified twenty- 
two skin diseases which have been attributed (1) to vaccine virus; (2) to 
mixed inoculation, and (3) as sequela? of vaccination. 

Sex alone exerts little influence until the approach of puberty. There- 
after, the greater divergence in the habits of the two sexes has a modifying 
effect only less pronounced than the physiological differences of the mature 



ETIOLOGY 29 

male and female. These latter differences reach the point of exclusion in only 
two diseases — 6ycosis does not occur in the female, and Paget's disease of the 
nipple does not often occur in the male. As causal events peculiar to women, 
menstruation, pregnancy, lactation aud the menopause require notice. 

Menstruation more often a^ sting eruptions by the recurring 

disturbances of the circulatory or nervous systems; but, if excessive, it may 
lower nutrition and create a predisposition to cutaneous i Such 

disi ma, urticaria, acne and i ire frequently worse shortly 

ippeaiance of tl bale transient erythema, herpes and 

purpura may appear only at the monthly period. Bloody sweat (lueinati- 
droaia) baa been observed in amenorrhea; likewise, excessive local or general 
perspiration, with or without reenltu ma or eczema, is not uncommon, 

may be attended wiii _, r pruritis vulva?, or the itch- 

may I" i associated with urticarial Lesions. 

chloasma is quite common, herpes simplex is often seen, herpes gestationis 
• iuite rare, and impetigo herpetifon fortunately, 

ly rare. With t iptions incident 

then ar. 

tation, like d agia, may tend more to aggravate chronic erupt 

than to .s. This is probably due to a lack of cutaneous 

vitality from a rted nutrition. Tin. ma, 

which may ' I during pregnancy, are liable to return during Lacta- 

rate 

ah in in 

ua and 
ine 
e pronounced in f womai 

//■ r, ■■'■hi. Mai i ii. .n-i. 

lired inherit ,]y ichthyosis, am 

rematun and possibly . 

' unlikely t! 

rid wholly due to in u of BOme dia- 

•>t uniformly pro of skin may 

family thr<- 

:it. It has K.-en 
oed as ai proclivity to definite 
forms of disease. 'I n of diathes ted 
nic disease. In the cutaneous mon dial iich 
•iie rheumati - and exudative ery- 
thema ; the stnr ment of ma, 
aene and Lmp< tigo. 

■i diseae ! to tropical 



30 ETIOLOGY 

climates, e.g., leprosy, delhi boil, yaws, etc. Warmth of atmosphere seems 
to favor outbreaks of urticaria papulosa, miliaria rubra and intertrigo; in 
cold weather, eczema, psoriasis, seborrhcea, lupus, ichthyosis and pruritus are 
aggravated, or tend to recur; chilblains and dermatitis hiemalis originate 
in cold weather, boils and erythema are most frequent in the changes of 
spring and autumn. Sudden changes in temperature may cause greater 
activity in many existing eruptions or a fresh efflorescence. 

Occupation. Fissured eczema is common in plasterers, masons and wash- 
women, whose hands are frequently brought in contact with alkalies. Those 
who handle animals or animal substances, as herdsmen, tanners and butchers, 
are most liable to anthrax and ecthyma. Occupations necessitating exposure 
to heat, as with cooks, blacksmiths and firemen, are favorable to attacks of 
erythema, eczema and dermatitis ; while workers at oil refining, tar distillation 
and in aniline color making, etc., are peculiarly subject to the latter disease. 

The dwelling and clothing, often in connection with uncleanliness in 
various forms, are promoters of skin diseases. The air of houses and rooms 
polluted with sewer gas and other noxious emanations are favorable conditions 
for the occurrence of pemphigus in young infants, furuncles and strumous 
diseases; and, associated with uncleanliness of the person, largely diminish 
the resistance of the skin to the invasion and multiplication of animal and 
vegetable parasites. Soiled flannel and other underclothing, long worn, favors 
the development of seborrhcea of the body and eczema; while too light or too 
coarse garments, or the presence of irritating dyes in clothing, may excite 
excoriations, papular eruptions and pruritus. It is to be borne in mind, 
however, that eczematous eruptions are usually made worse by indiscriminate 
use of water, and that too much or too frequent scrubbing of the skin with 
poorly made soaps may excite some form of that polymorphous disease. 

Effects of existing disease: Oastro-intestinal disorders, dyspeptic or catar- 
rhal, nearly always accompany the early onset of rosacea, and only less often 
bears the same relation to urticaria. Erythematous, acnoid and eczematous 
affections also, at times, appear to originate from alimentary disturbances. 
The relation of food in quality and quantity to disorders of the digestive 
tract and associated skin eruptions is not to be overlooked. Infant foods, 
containing undigested starch, are frequent sources of cutaneous erup- 
tions in infants and young children; but, at all ages, food may be an im- 
portant factor. Certain individual idiosyncrasies in respect to one or more 
articles of diet may also have a direct causal relation. Diabetes mellitus pre- 
disposes strongly to the formation of boils, carbuncles, cachectic acne, urticaria 
and erythema. Glycosuria rarely produces a characteristic papulo-pustular 
eruption (xanthoma diabeticorum), unaccompanied with any subjective symp- 
toms, but which rapidly disappears with the relief of the diabetes. Pruritus. 
with or without secondary eczema, especially about the genital region, is fre- 
quently caused by diabetes. Of less practical importance is the superficial 
and terminal gangrene of the skin, which occurs sometimes in the advanced 
stages of the disease. Eczema, purpura, urticaria and general pruritus are 



ETIOLOGY • 31 

occasionally observed in the course of chronic nephritis in old people. In 
the advanced stages there sometimes appears upon the skin an erythema, 
which, at first, may resemble measles or scarlet fever, but the patches of erup- 
tion soon coalesce and may become generally diffused. Desquamation in large 
flakes follows, leaving the skin infiltrated, red and sometimes eczematous. 
This uraeniic erythema is of grave prognostic significance. 

Spasmodic asthma is frequently enough observed in association with 
eezenja, acne, urticaria and ichthyosis to lie named as a cause. The author 
had a case of -pityriasis rubra pilaris under observation, in which the periods 
of aggravation were attended wit; asthma. LUhamia and jam 

are common causes of persistent pruritis, with or without an attendant erup- 
tion due to scratching. Chronic jaundice, from whatever origin, frequently 
stands in etiological relation ng multiple xanthoma; while simple 

xanthoma of t la, on the other hand, in the majority i ids in 

sequent relation to migraine. Incidentally, tfa how the same patho- 

logical disease, though clinically unlike, may arise from totally dil v 
causes. Chronic constipation may induce pigmentary deposits m the skin 
or chloasma. A rare affection named chromic 1 which I I and 

- the sebaceous s, , ., result of consti- 

pation. A theoretical explanation of tlored sweat is, that mdol 

lorhed from the : ee, and changed in its elimination into 

n and indigo. Bowever ft be, cure of t: pation h the 

in. Chloasma patches 
on the skin occur not infrequently in pi li. from 

tsionally they are symptoms of abdominal can- 
* a contracted liver. '1; the skin, from Add 

iphthalmic goitn known. In the 

and limit 
freckles ahout resemble leucoderma. In old aire pigment 

patch) i an son etimi n of the skin. 

istitutiur ly with characfa 

ehaoj those mentioned, i >fula, 

pyssmia, BCUTV] and malaria. I ''onus of malarial d 

frequently prod; the skin, herpes and urticaria: 

leas often, erythema and purpura -till less commonly, furuncles and 

lently determine the location and extent of 

eruption, hut the cutanci ly no niea 'ant. and the 

character of tin- eruption is far from uniform, if t the variel 

zoster which are 1 to !»«• always dm- to an inflammation of some part 

of th trunk or ganglion, having terminations in the affected area. 

nich as L r r«at fright, L r ri''f. etc.. do sometimes transmit to 
the trophic nerve powerful impressions enough to cause bleaching of the hair, 
baldness, eczema, severe pityriasis and psoriasis; hut all of these may follow 
quite different ca 



32 ETIOLOGY 

Marked variation in the degree of nutrition resulting in plethora or debil- 
ity, while not strictly diseases, if persistent, establish a predisposition to 
disease. Plethora predisposes to superficial congestions and inflam m ations 
of the skin, and tends to make them less tractable to treatment. Such over-fed 
individuals are more liable to attacks of eczema, pruritis, etc., from trivial 
causes. The debilitated are much more prone to attacks of seborrhcea, furun- 
cles, carbuncles, ecthyma and impetigo than those who are well nourished. 
Defective nutrition and impaired functions of the skin probably also have 
much to do with the ease of lodgment and growth of parasites; the invasion 
of pathogenic germs or the absorption of contagion. Some persons are readily 
infected by contact, while others remain wholly immune after exposure. This 
difference can only be accounted for by constitutional or local loss of vigor, 
some anatomical peculiarity or change in quantity or quality in the protective 
secretions of the skin. 

Drugs in small or large doses produce nearly all the elementary eruptions 
of the skin. With few exceptions, drug eruptions are not a constant effect 
or uniformly characteristic. The eruptions which are caused by quinine, 
copaiba, belladonna, iodine, bromine, chloral, etc., will be referred to in detail 
under dermatitis medicamentosa. 

Thus far it will be seen that the general or predisposing causes of skin 
eruptions are both numerous and plainly related. Yet, in many instances, 
we are unable to demonstrate the direct connection between them and the 
cutaneous disturbances caused by them. This may be, in a measure, due 
to the operation of several or many factors at the same time to produce 
morbid conditions of the constitution or of separate organs or parts not under- 
stood or easily defined. The psora of Hahnemann finds little place in the 
modern etiology of dermatoses, and, in its narrow sense, deserves none. But, 
with a broad interpretation of its intended meaning, it might well stand for 
those indefinable states of constitution which underlie many chronic skin 
diseases, and, at the same time, prevent a too ready neglect of the relations of 
general pathology in the active search for the local or direct causes of erup- 
tive diseases. 

The direct causes of skin diseases are external in origin and do not neces- 
sarily bring about any disturbance in other organs; or, if they do so, such 
disturbances are secondary to the skin disorder. Some of these have been 
already named under the more general head of occupation, etc. Idiopathic 
skin lesions, unlike the symptomatic, have a distinct relation to the nature 
and action of the causes which produced them. These causal factors, accord- 
ing to their nature, may be chemical and toxic, mechanical or parasitic. 
Chemical agents may excite irritation, inflammation, or destroy the superficial 
and deep layers of the skin when brought in contact with it. The degree of 
injury will depend on the nature of the irritant, the duration of the applica- 
tion, and the sensitiveness of the part involved. Agents of this class are verv 
numerous; they include many plants which contain an active principle dele- 
terious to the skin, such as arnica, ivy, sumac, mustard seeds, etc. ; most of the 



ETIOLOGY ; ! ; ! 

ethereal oil> ami resins; the poisons introduced into the skin by the stings 
an<l bites of insects ami reptiles, such a> 1 >* **.*> . mosquitoes and snakes; the 
various antiseptic preparations, when or over-used, such as iodoform, 

corr blimate, carbolic acid, and creolin; substances used in the pro* 

of manufacturing d aniline dyes; strong a< dtric, muriatic, 

sulphuric, acetic and lactic-: the stronger alka lustic potash; the effects 

of heat, from unusual exposure t<> the rays of the sun, from over-exposure 
j, or from the radiation from heaters or Barnes, or from actual con- 
tact, and ah oold. To these might be added the effects 

n chemicals used in the various trad< • tntly unavoidable, and espe- 

cially the many medicated applications, often unnecessary. It is to be borne 
in mind that chemical irritant- ma;, not l>e limited in effect to the area of the 

•i directly acted upon: hut. through their influence <>n innervation, ma\ 
sturhano mm points, or, from weakening the resistance of the 

;. permit otl Regarding thi> relation 

medicinal irritant-. Kap irell said, "These relations are altogether too 

little known, for, it' they were, physicians would not use cutaneous irritants 

riniinatelv." 

Mechan ncidental to nearh tive employ- 

men! of mankind, and ma\ ait to produci the epidermis or deeper 

ch commonh promotes health, if too 

_ continued, without proti f the sui [ .ml con- 

■ inflammation. Frequent or pn contact with water, m> the 

hand- of a laundress, ia apt to < as which constantly 

the hands to irrif - w n!i b ind 

■ tend i eruptions. Intermittent pressure, 

in the work of shoemakers, bUu uing of the i 

us layer of the epidermis, known aa callus; while prolonged pressure over 

from ;i tight -hoe. in,i\ produce davi. Tightly encircling bands 

and itruct the local circulation, maj induce swelling of the skin 

or enlargement of the veins. B other causes of mechanical 

irritation not named, ami incident t cupation and habits, are the excori- 

ii- from scratching with the finger nails, and all sorts of accidental abra- 
ns, bruises and l . to wh one is more or 

liable. 

Pat iher ammal or vegetable in origin. Modern methods 

of investigation have demonstrated the etiological relation of parasites to a 
_-e number of <km diseases. In the majority of these diseases the 

aovi n as mi« bacilli, etc., 

I to cause a considerable number of cutaneous diseases. Tl 

tblished in favus, the form- <>f ringworm 

and tn The) are found in the lesions o irbuncle. 

furuncle, erysipelas, leprosy, tuberculosis cutis i lupus vulg i . and other 

Minion .1 They probably enter inl syphilis, 

molluscum epitheliale, po*wibl\ if eczema and some 



34 DIAGNOSIS 

affections whose etiology is now obscure. It is but proper to say that scientific 
proof of the etiology of micro-organisms to skin lesions, according to the laws 
of Koch, is wanting except in a few diseases. On the other hand, observed 
facts in clinical history, curative and preventive therapeutics, justify the belief 
in such an etiology of wider influence, and emphasize its importance to der- 
matology. Animal parasites, comparatively few in number, are well estab- 
lished as essential causes of cutaneous lesions. Some dwell upon or in the .skin 
in a permanent way, as the itch mite, filaria, etc.; others, as the bedbug, 
body louse, etc., only seek the skin at intervals to obtain food therefrom. 
The lesions produced by animal parasites may be ephemeral wheals or ery- 
thema; sometimes vesicular and pustular inflammations of longer duration, 
or permanent and disfiguring, as in parasitic elephantiasis. The healthy and 
intact skin does not probably afford the proper soil for the habitat of most 
vegetable or animal parasites; hence, some predisposition may be the first 
element in the etiology of these diseases. 



DIAGNOSIS 

In the discrimination of skin disease it is not enough to say it is papidar, 
pustular, etc., but in each individual case it should be recognized broadly as 
a clinical entity, beginning with its earliest manifestations and ending with 
the evolution of its lesions. Knowledge, therefore, of general and special 
pathology, symptomatology and etiology, united with trained observation of 
minute details and sound judgment, are essential to accurate diagnosis. While 
special diagnosis will be considered in connection with separate diseases, there 
are general methods which are profitable to study by themselves, as illustrat- 
ing a system of collecting and grouping facts for the purpose of diagnosis. 
If it appears that an expert diagnostician arrives at a differentiation of 
disease by a rapid survey of symptoms, etc., it is a mistake to infer that his 
expertness was attained in any other way than by systematic methods of 
inquiry. An effort should always be made to see things as they are found, 
and not hunt for facts to fit a name, which is the last if not the least in 
importance. As sight and touch form the chief means of examination the 
patient should be seen in good daylight. Direct sunlight or artificial light 
modify color, especially the shades of yellow, to such an extent as to be at 
times misleading. The room should, if possible, have walls of neutral tint 
so as not to reflect their color upon the skin. The temperature of the room 
should be such as to permit the exposure of the skin, in whole or part, as may 
be necessary, without injury to the patient. The inquiry may now be con- 
ducted regarding facts which pertain to the patient, the disease and the 
lesions. 

The following grouping after Crocker, somewhat modified, will be found 
a useful guide for the student in this line of investigation : 



DIAGNOSIS : ^"> 

Patient. family history, occupation, mode of li 

ins, eeneral health. „ 

(Name, i 
DtstHse. —Symptoms, duratioi isation. 

its. — Kind and character, evolutii ibution, ,> ' ■ 

I rogn. 

The patient's family and personal b ige, sex, occupation, mode of 

livu plexion, general asp' or local disturbances are to be 

not mainly iiapter on etiology, to which 

student is referred. Family history may me hereditary influen 

personal history, the previous existence of other disease, or previous atta 

\he same disease, as is not ui d in psoriasis, eczema and urticaria. 

If ode of living may bare ^ed to plethora or 

mm. Local distnrbanoe in i is apt to : 

ia and ci 
The disease manift I by symptoms of a general 

which may iptiou. nstitutional disturb- 

fever in must of the 
innammato: tally in eczema and the para- 

n diseases; burning ->r tieiiraL 3 these set 

fit int'i the clinical history. The same 

: of the odor .dor in 

hilitic i) d variola and gangr. 

ration a An eruption lasting continu- 

!v two or n lude tli>- erupt r. of 

thema and urticaria longer, with remis- 

lasting for months or yet 
like the more usual chi •■. rossoi lepra, lupu- The 

rse of the disease the eruption appear all 

pemphigus; or continuously, 
resolving? Did it extend by more 

ma, 
ption primal d by the stages of evolutions, 

. multiforme; or i lined b] Qg or local methods of 

. tin.nt !- \- th< l* queries an anawi went by the 

patient, due all' g for inaccuracies of descrip- 

tion and misuse of terms. F ten required to elicit the 

ally in erratic history may be 

The lesions, t I titration, evolution, etc., 

■ffOrd ' ' a lliell the III ! t)L r file |ia- 

■1 and the disease ten or modify. The kind of lesion, whether 

pap and pi ; >>r papulo n acne, eczema; 

or v r multiple li : i i lis and many cs 

ema. The pn induration in <>r about them; signs 

inflamma heat, swelling and color, or color due to other pathological 



36 DIAGNOSIS 

changes, as the yellow crusts of favus, the violet red hue of lupus nodules, etc. 
In the earlier stages of an eruption, lesions are most likely to show typical 
forms, unchanged by evolution or artificial means. Even when such changes 
have occurred, the edges of an active patch will frequently exhibit the 
original form of lesion. Secondary lesions may indicate the primary form, 
as the yellow scabs from previous pustulation, the light yellow to brown or 
blackish crusts from the drying of serous, seropurulent and bloody discharges ; 
the ulcers due to degeneration of infiltrating growths, as from syphilis and 
lupus vulgaris. Tims, also, is their pathological character and evolution 
partly ascertained. 

The identity of a lesion may be made clear by observing its peculiarity of 
evolution. Lesions may spread by peripheral extension, and, at the same time, 
clear in the centre, as seen in ringworm of the body, erythema iris, etc., or 
without tendency to clear centrally, as in seborrhceal eczema. When adjacent 
rings expand to meet each other, the sections in contact disappear, while the 
free border continues to extend, forming irregular curves and figures, as in 
some cases of psoriasis. 

The distribution and extent of lesions may be characteristic. Symmetrical 
arrangement of lesions is usually due to constitutional influences, or to the 
presence in the circulation of irritants or poisons; examples of which are the 
lesions of the eruptive fevers, and from the ingestion of the iodine salts. 

Unsym metrical distribution of lesions is largely due to agents primarily 
acting upon a local part, as the local infection in lupus vulgaris, or through 
the nerves of a part, as in zoster. Universal distribution of lesions may occur 
in pityriasis rubra, pemphigus foliaceous; and a general distribution in many 
erythematous affections, eczema and psoriasis. The lesions in some skin 
diseases commonly begin in certain regions; as. for instance, seborrhceic 
dermatitis upon the scalp, psoriasis upon the extensor aspect of the elbows and 
knees, and thence by preference to the other extensor surfaces. The general 
tendency of eruptive diseases to develop in certain regions is shown in the 
table below, from Pye Smith, as modified by W. A. Hardaway. 

Scalp. — Eczema, seborrhcea, alopecia, alopecia areata, psoriasis, steatoma. 
favus, syphilis, ringworm (in children), pediculosis. 

Face. — Forehead: Chloasma, acne, syphilis, psoriasis, zoster, epithelioma. 
Eyebrows: Seborrhcea, alopecia areata, alopecia syphilitica. Eyelids: Xan- 
thoma, eczema tarsi, milium. Nose: Lupus, syphilis, epithelioma, rosacea, 
rhinoseleroma, seborrhcea. Nose and cheeks: Bosacea. lupus erythematosus. 
Nostril orifice: Folliculitis, impetigo, herpes. Upper lip: Eczema, herpes, 
lupus. Lower lip: S3philis, epithelioma. Mucous membrane of mouth: 
Herpes, syphilis, measles, small-pox, lupus, leucoplakia. lichen planus, pem- 
phigus. Bearded face: Sycosis, pustular eczema. 

Ears. — Lupus erythematosus, syphilis, lepra, xanthoma tuberosum, eczema. 

Neck. — Eczema, scarlatina, intertrigo, furuncle, carbuncle, sveosis. 

Back. — Acne, tinea versicolor, seborrhcea, pediculosis, carbuncle. 

Chest. — Scarlatina, varicella, syphilis, keloid, seborrhcea, lenticular cancer. 
Breasts: Keloid, eczema. Nipple: Eczema, scabies. Pagefs disease. 




DIAGNOSIS H7 

- of trunk. — Zoster, syphilis. 
Abdomen. — Typhoid and typhus rashes, tinea versicolor, scabies, syphilis. 
Umbilicus: Scabies, erysipelas, carcinoma. 

Scrotum. — Eczema, pruritus, syphilis, elephantiasis. 
Prepuce. — Herpes, scabies, syphilis, chancroid, eczema. 
Nates. — Furuncle, carbuncle, scabies, sypbJ 
Anus. — Pruritus, eczema, mucous tubercles. 

Elbows. — Flexor side: Eczema, xanthoma planum. Extensor Bide: Peon- 
is, xanthoma tuberosum. 
Forearms and backs of hands. — Erythema multiforme. 
Wrists.- Flexor ride: Bcabiee, lichen planus. Extensor side: Small-pox. 
II mills and j" t.— E dloaitas. 

Palms "nil soles. Syphilis, eczema, Fingers and toes: Chilblains, pom- 
pholyx. NTails: Hypertrophy, atrophy, onychomycosis, onychia, paronychia. 
In and groins.- -Intertrigo, eczema, ringworm, erythraama. 
Thighs. — Extensor side: Prurigo, ki pilaris. 

AV Flexor side: Eczema. 

Legs. Eczema, erythema nodosum, ulcer, purpura, ecthyma. 

• mi mi.- the line of in. pun can be carried farther and the 'tints 

of lesions noted, such as the pigment stains which may be left by the lesions 

of syphilis, lichen, ai the disfiguring rofuloderma and 

lupus vulgaris, the smooth, delicate ci< iperficia] syphilitic oleer- 

ations. ('are iim-i be Died to discriminate between lesions natural to the 

morbid process and those which result from external influences, such as the 

blood crusts, excoriations, wheals, etc., from scratching, or from changes 

iit aboui by soothing, -timulatn al treatment. 

borne in mind that two >>r more diseases may co-exist, in 

which oik- may more or less completely mask others; thus SCZCma may he 

fted on a lupus erythema! vphilitic ulceration disguised as lupus 

vulgaris; scabies complicate s ; or impetigo change the clinical .1 

of 1 varicella. Certain lesions are pathognomonic whenever found in ac 

stion with other signs of s disease. Such are the sulphur-yellow cup of 

favu-: the broken "stubble" like hair in tinea capitis; the DUITOWS of the itch 

mite; tl ra on the hairy part-, and the hemorrhagic points on the non-hairy 

parte, in pediculosis; the flat, glistening papules in lichen planus; and the 

apple-jelly nodule- of lupus vulgaris. 

Tie "f a cutaie ise will frequently be learned during the 

collection of facts relating to the patient, the symptoms and the nature of 
the lesions found, aided by ■ knowledge of general and special etiology. The 
presence and nature of othei max be demonstrated by 

methods <»f examination adapted to such disease, as clinical analysis of the 
urine in affections of the nrinan organs, or laryngoscopic examination in 

of syphilis, cancer, lupue and leprosy. The microscope aids in the detection 

of parasites, and may further aid diagnosis in demonstrating the nature of 
aeopli . in doubtful cases Bacteriological has enabled 



38 TREATMENT 

advances to be made in etiology and pathology. In no other branch of medi- 
cine has such strides been made in recent years; and this method of investi- 
gation may at times be available in establishing both the cause and the diagno- 
sis of obscure cases. A diagnosis should never be made without sufficient 
examination. Occasionally even the most expert dermatologist may require 
repeated examinations before arriving at a positive conclusion. The same 
facts which enable the physician to distinguish one disease from others furnish 
important indications for treatment (discussed below), and these again to- 
gether with a knowledge of the probable effect of treatment form a basis 
for prognosis, i.e., the probable course or termination of disease. 



TREATMENT 

No principles or art of therapeutics of the skin can be scientific or practi- 
cal which disregard the varied relations and the equally varied functions of 
the cutaneous structure. That therapeutic principles founded on such a 
basis alone can be wholly scientific is not claimed, because knowledge of 
function and the mode of operations of external and internal forces or influ- 
ences upon a part are far from complete, yet certain relations and needs are 
unmistakable and point to the advantage of classifying principles in accord- 
ance therewith. The value of a principle of therapeutics must depend on the 
stability of truth or facts which underlie it and its utility in the art, with 
or without strict regard to the details of its application. Therapeutic principles 
prevent hap-hazard prescribing, they conserve time, but they need not limit 
freedom of thought or abrogate common sense. 

To meet his own needs in treating diseases of the skin the author has 
classified treatment under five heads, each of which indicates a special purpose, 
but which may merge into another in application without loss of identity 
or conflict in action. Individually they stand for nothing new; collectively 
they may represent a convenient system of inquiry as to what is required in 
the treatment of a case, whether: 

Causal (antiparasitic, etc.^. 

Physiological, 

Pathogenetic, 

Mechanical. 

Operative, one or more. 

Etiology becomes at times a basis for a principle or treatment which may 
or may not fall within the sphere of other principles, therefore it is best 
considered by itself. 

Causal treatment implies the use of means to remove the obvious 
causes of disease. Perhaps its most common application is in the destruction 
of parasites. While the latter do not represent the whole etiological factors 
in such cases, neither prevention nor cure permits a disregard of their rela- 



TREATMENT 39 

tions as exciters or disseminators of certain disea>e?-. Among the parasiti- 
cides ichthyol, thiol, rcsorcin, carbolic acid, naphthol, lysol, creolin, trikresol, 
formoiin (saturated aqueous solution of forty per cent, formic aldehyde). 
-ium permanganate, iodine, hydro >.cid'', corrosive sublimate and 

sulphur, may be mentioned. 

Causal treatment may call for operative measures, as in a case under my 
observation, where an intractable eczema of the face was easily cured after 
the removal of a nasal polypus. Chloasma, partly due to resorption of coloring 
matter from the intestines, may often be cured after sufficient removal of 
the effete intestinal accumulations, whether attended with constipation or not. 
A daily stool is not always a sign of efficient intestinal elimination. Faecal 
tumors may e\<n exist in the presence of a diarrhoea. Take, again, a case of 
Bt in a person who habitually over-indulges in stimulating food, especially 
beef and hot liquids, of what benefit can an attenuated remedy be to such a 
patient without first correcting the causal excesses of diet? Causal treatment 
employ any of the f"' irinciplec re in nature, or it may be 

negative and be typified in "don' 

Physiological methods eonsisl in the use of things winch properly used 
or regulated ordinarily oontril benefit oongi 

ichthyosis by change of din epidermic exfoliating 

Ml by the pi ternally and internally. Physiol 

often l" oon-cul Sections, such as, 

for instance, nephritis or dish - of acne 

indurata ever nndi Iped little b\ treatment with indicated 

drugs until in searching for a onnd, 

ed. A p] 
.illation of diet soon told favorably upon ; 

• infrequently the chief excitant of pruritus, 
[nstai illustrating the value of 

ition, b.i S< want 

all thi quire 

a chronic cut., i a phj - irma- 

ti.>n. M : i r i . of i'. natural spring waters of this ...nun-, and the Continent 
due. bin with the 

relief from business and ■ in a bug ee for 

the marvelous one <>f t h<- health res 

However, the path irious mineral waters, adminis 

ile. 
Pathogenetic therapeutics is a ride field and beyond I 
contribution. Mam rathor in tin irity of homoe- 

opathic medication, and are rery likely thankful that it is not a question of 
doubt, but mally fin'l it difficult to correctly apply, because we di 

know enough about it. These difficult so great in cutaneous 

added t" subjective indications. The 
principles, however, s me and ..n which to hang a prescrip- 



40 TREATMENT 

tion, i.e., location, sensation, aggravation and amelioration, are just as valuable 
here as elsewhere and there are no bodily limits as to location of symptoms. 
Pathogenetic therapeutics may be external, however, as well as internal. In 
this respect the exposed mucous surfaces and the skin cannot be viewed thera- 
peutically like other tissues, subject as they are to direct external influences. 
The indications from pathological change can sometimes best be met by local 
remedies which produce immediate pathological effects. This is the chief 
basis, I believe, for local pathogenetic treatment. ^Repressive measures are 
inadvisable and often dangerous, but substitutive irritation is often curative. 
Take a case of long standing eczema, for example, with pronounced changes 
in the structure of the skin. Such a case we may cure by internal treatment, 
but if not soon responsive to a remedy the immediate application of some sub- 
stance that will produce a similar irritation or inflammation may be of great 
service. It would seem that to produce a reaction is often the most scientific- 
way to cure a chronic skin disease. This may be achieved by the external 
application of such drugs as tar (crude or distilled), ichthyol, carbolic acid, 
pyrogallol, chrysarobin, anthrarobin, iodine, formalin, etc. ; or by the use of 
physical agents, such as heat, light, Rontgen rays, radium, high frequency 
currents, etc. ; or by internal medication in physiological doses of such remedies 
as mercury, or the iodides; or by the administration of serums or toxins, like 
streptococcus serum, tuberculin, thyroidin to produce reaction. 

Mechanical treatment is nearly always auxiliary to other methods. The 
nature, functions and exposures of the skin may call for protection, lubrica- 
tion, support, compression, etc., by the employment of non-medicated lotions, 
oils, ointments, pastes, varnishes, bandaging, posture, etc. The even com- 
pression of the skin from prolonged immersion in water is sometimes of marked 
effect, not only on the superficial surface, but as well upon the tissues beneath. 
Thermal effects may also be obtained through this medium. Mechanical 
treatment of the skin, if not alone curative, promotes comfort, which is no 
unimportant feature of most remedial measures. 

Cleansing, soothing (and practically non-medicinal) lotions may contain 
peroxide of hydrogen, one part of the ten volume strength to two to five parts 
of water; boric acid in saturated solution or reduced one-half with water; 
borax in two to six grains to the ounce of water : boro-glyceride (fifty per 
cent.), one part to five to twenty of water; carbolic acid, one part to sixty of 
water; benzoic acid, one to fifteen grains to the ounce of water; bicarbonate 
of soda, five to ten grains to the ounce ; electrozone, one part to four of water : 
enzymol, one part to one or two of water. Common salt may sometimes be 
added to water with advantage for general use, and alcohol can be used diluted 
with ninety per cent, of water, up to its full strength. A small proportion of 
glycerine may be added to lotions sometimes with advantage, but glycerine 
in large per cent, is seldom of value. Soft soap made by the addition of 
caustic potash in an excess of three per cent, to an animal fat. may be neces- 
sary for its detersive, stimulating or mildly destructive effects. 

Oils, such as the sweet almond, castor, cotton-seed or olive, can be em- 




TREATMENT 41 

ployed alone, or more often combined with other substances, especially with 
more solid fats to lessen their consistency. Simple ointments may consist 
of fresh lard alone, or combined with wax to give it firmness; of lanolin com- 
bined with sweet almond or olive oil to lessen its adhesive qualities; and of 
vaseline alone or combined with paraffin in the proportion of two to one. 
Neither vaseline nor lanolin is adapted for application in acute inflamma- 
tion. The wide use of oxide of zinc ointment probably comes from its admi- 
rable protective qualities and its total medicinal inertness. It can be applied 
as freely a.- the simple fats; the benzoated ie occasionally preferable. Oxide 
or tubnUraie of bismuth in ten to twenty grains to the ounce is also protective 
and mildly antiseptic; salicylic acid in five to twenty-live grains to the ounce 
of simple ointment appears to have a purely mechanical effect on the thick- 
ened epidermis, loosening and separating the oornefied epithelia. Applied 
to non-hvpertrophic skin it may produce decided pathogenetic effects. Boric 
add in fine powder ..f ten to thirty grains to the ounce of lard or lanolin 
ointment is alone protective and gently antiseptic. The same may be said 
of gomenol (five per cent.), gallanol (one to three per cent.), calendula (five 
to twenty-live per cent.) and nmm //•// (one per cent.), each in a 

simple ointment 

For antipruritic effects carbolic acid, thiol, vchthyol, adrenalin, orthoform. 
iodoform, calamim in, etc, are used in simple ointment, in rose water, 

dilute alcohol, glj r m a combination of these, or in some alkaline 

vehicle like the milk of magnesia. 

Inert or hygroscopic powders may frequently serve to protect surfaces and 
nt parasitic invasion. The simple powders of finely pulverised starch. 
talc, leaolin, lycopodium, etc., will often suffice alone. When there is 
moisture to be neutralized the addition .if impalpable boric arid powder to anj 
of the above, except lycopodium, inc r e ase s their efficiency, and oxide of tine 
adds to their soothing qualities. OaUdnol in five to thirty grains t<» the ounce 
of simple powder L r i\e- to it sometimes increased efficacy when the skin is 
sensitive and tender. The compound ttearaU of :ini powder is of special 
mine on dry opposing surfaces. It maj be necessary to procure a mild stimu- 
lating, antipruritic, or antiseptic effect, and for this purpose iodoform, aristol. 
europhen, noeophen, ichthyol, reeorcin, bismuth, acetanilid, calamine, or car- 
bolic acid, in powder form, niav be added to the simple dolomol or stearate 
of zinc compound. 

Occlusive protection ie rarely adapted t" other than small areas of com- 
paratively immobile skin. Ordinary collod imetimes of service painted 
over a patch before exudation has begun, OT over dry lesions after removal 
of the Scales. I' the double purpose of hermetical protection and 

mechanical compressiori "ii the over-full hi l-vessels. Over the thickened 

horny tissue the addition of three per cent. Or less of Balicylic acid git 

it a special effect in removing the corneous epithelia. A ten per cent, solu- 
tion of gutts perchs in chloroform, known as troumaticin, is sometim* 

be preferred to collodion, especially when it is desirable t < ■ incorporate other 



42 TREATMENT 

substances with it, as oxide of zinc or chrysarobin; the latter, however, is only 
used for its pathogenetic effect. Pastes are flexible applications which have 
little advantage over other mechanically acting applications. The soft pastes 
have moderate absorbing properties which may be of value in an occlusive 
dressing and the further advantage of ready application without heating. 
Lassar's paste consists of powdered starch and oxide of zinc, of each two 
drachms, vaseline one-half ounce. Ihle's paste is composed of equal parts 
of lanolin, vaseline, starch and zinc oxide. To these pastes other substances 
are added to give them medicinal powers. They are not essential to their 
protective function. Hard pastes contain gelatin and glycerine in some 
proportion. One of Unna's pastes is as good as any, perhaps. It consists of 
gelatin and oxide of zinc, each a drachm and a half, glycerine three drachms, 
distilled water four drachms. When used it has to be melted in a vessel 
placed in hot water ; it is then painted on the part and a layer of cotton-wool 
placed over it to prevent its adhering to the clothing. It is only adapted 
to dry surfaces, and then only in cool weather. It has been used as a vehicle 
for other substances, but is inferior to other vehicles where pathogenetic 
effects are desired. Varnishes, so-called, may be occasionally useful. One of 
the best is Elliott's oassorin varnish, composed of bassorin forty-eight parts, 
dextrin twenty-five parts, glycerine ten parts, water seventeen parts. It is 
more stable than some varnishes which have been recommended, and it serves 
the purpose of an impermeable covering for small, dry patches of skin. 

Adhesive plaster vaay be applied for support, for pressure or to forcibly 
stretch the skin as in its application to remove wrinkles. 

Operative procedures in cutaneous diseases are of the simpler sort and 
consist of incision, excision, enucleation, scarification, curetting, skin-grafting 
and the varied applications of electricity and other physical agents. Many of 
these methods are pathogenetic, causal or mechanical as well as operative, but 
for the sake of brevity they have not been mentioned before. 

Instruments. — The use of the curette, the lances, the comedone extractor. 
the najvus, milium, irido-platinum and electrolytic needles, the epilating and 
grappling forceps, the cutisector, the scarifying spud, the multiple scarifier. 
the needle holder, the pleximeter and the various lenses is well understood 
and needs no further description beyond what will be found in the text. 
Plastic surgery may be useful in a few cases, and the same may be said of 
shin grafting as recommended by "Reverdin and Thiersch. 




Fig. 5. — Epilating Forceps. 



Fig. 6. — Electrolytic Knife. 



TREATMENT 



48 



In,, 7. — Irido-platinum Needle. 




- — Piffard'x Grappling Forceps. 




'*. — Piffard'e < 'utiaector. 



<i T tlUH LU 



n Milium Needle. 



— 1 



^■\\t<**-»* i»t* 



Fig. 1 1 Scarifying 




temoving i lectrolyaia 



i- Needle 




IS II.-- i llass Plexin - 



l'i>.. 16 Piffard'a \ I and 

Comedone Extractor. 



44 



TREATMENT 



Electricity. — Every year notes fur- 
ther advances in the use of the physical 
phenomena, and to-day no one, engaged in 
the practice of dermatology, can afford to 
be without a complete electrical outfit. 
The cabinet, as shown in the illustration. 
is a convenient and space-saving contriv- 
ance, because from it the X-rays, high 
frequency, galvanic and faradic currents, 
electrolytic power, diagnostic lamp, sinu- 
soidal effects and cautery may be ob- 
tained. 

The galvano-cautery and the thermo- 
cautery (Paquelin-knife) are used for 
their caustic and destructive effect, espe- 
cially in lupus vulgaris involving the 
mucous membranes. General galvanism 
has been used as a sedative while it has 
been used locally for pruritus and Eay- 
naud's disease and for the relief of the 
pain in herpes zoster. Faradic and 
static electricity are not used for specific- 
purposes in dermatology, but on the same 
indications that would call for their use in 
general medicine. 

Electrolysis accomplished by the aid of 
a galvanic battery is a useful agent in 

Fig. 17. — Electric Cabinet for X-Ray, hvpertrichosis. telangiectasis, warts and 
High Frequency, Galvanic and Fara- 1, ,-, T - ■, .-, -,- • _ 

die Currents; Diagnostic Illumination, other new growths. I nder the discussion 
etc. of the first named disease will be found a 

description of the technique. 
Radiotherapy, or the application of the Rontgen, or X-rays, is probably the 
most-discussed and widely used method of physical therapy. It is to Freund 
and Schiff that we owe our earliest knowledge of the use of these rays in 
dermatology. The following diseases may be mentioned as having responded 
in some degree to its use — epithelioma, lupus vulgaris and other forms of 
tuberculosis cutis, acne, rosacea, sycosis, ringworm, favus, eczema, psoriasis, 
hypertrichosis, lupus erythematosus, keloid, sarcoma cutis and mycosis fun- 
goides. The X-rays are indirectly germicidal, through tissue reaction, as is 
shown by the cessation of purulent discharges in eczema and cancer after 
their application. Cells of embryonic type become degenerated without the 
surrounding healthy stroma being affected, and hence it is possible for hair 
follicles and sebaceous glands to become atrophied when subjected to the 
X-rays. For the clinical behavior and pathological action of the Rontgen 
rays, the reader is referred to the section on Rontgen Bays Dermatitis. 




TREATMENT 45 

Apparatus. — One of two forms may be used — either the static- machine 
or an induction coil with electric current or storage batteries attached. The 
coil may have a double or triple winding in the primary, which should be 
connected in parallel or in scries and should furnish a .-park gap of 30 cm. 
Of the four interrupters that are in use, each ) individual advantage-, 

and are known as the turbine and the dip interrupters (both using mercury)., 
ectrolytic and the vibratory interrupters. A voltmeter, ammeter and 
tachometer may be used to indicate, respectively, voltage, amperage and fre- 
quency of interruptions. Lead plate is usually placed between the patient and 
the tube, an opening being mad.- Blightly larger than the area which is to be 
!. Ronl red that lead on d inch thick was 

impervious to till raj's, but in practice one thirty-second of an inch is -urti- 
ciently thick. The Friedlander Bhield, or bond (see illustration), is a con- 
venient method oi «rhen it tan be used. Aluminum screens have 




Fk. i^ I riedlander II i 

in the treatment of deep !• a- to intercept the rays 

which cause an earlj dermatitis. The subject of tubes admits of much honest 
difference of opinion. Tubes are known a- "hard" and "-oft." The former 
- marked ce to the pa the current, because the vacuum 

datively, men It- i penetrating, contain fewer of the 

superficial and hence the -km i> not affected quickly, but only 

after a Dumber of exposures. Naturally the characteristics of the -oft tube 
an- the i. this la-t variety that are better suited for fluoroscopic 

work, because the contrast between flesh and bones is more evident. When 
possible a regulating device Bhould be attached to all tube.-, because tubes 
become hard from u-.'. while rest will -often a hard tube to -nine d( - \ 

new tube will give out more .\-ra\s than an older one. 

It i- impossible t<> define any exact method applicable to all 
there i- ii. i mean- ■>( measuring the radiations of any single 
tube, and further individual susceptibilities must he expected. To offset this 
latter difficulty, preliminary exposures should always be instituted before •> 
regular course of rayii rted. These are given daily for three or four 

days, for about live minute-, at a distance of five inches. If no unusual 

tion occurs at the end of two or three week-" time, the regular treatment may 



46 



TREATMENT 



be instituted. Schiff and Freund have suggested that the coil should furnish 
a spark gap of 30 cm. ; that there should be a primary current of 12 volts and 
1 1-2 amperes, with interruptions of 600 to 1,000 per minute; that the tube 






Fig. 19. 



Fig. 20. 



Fig. 21. 



Figs. 19, 20 and 21 show different types of Crooke's tubes, Fig. 21 showing a tube with 

automatic vacuum adjuster. 

should be placed 15 cm. distant from the lesion treated, gradually reducing 
the distance to 5 cm., and that the time of the first regular treatment should 
be five minutes, which may be increased gradually to fifteen minutes. Treat- 
ments should be given once, twice or three times in a week. As regards the 
choice of tubes, it may be said in a general sense that soft or moderately soft 
tubes are needed for the treatment of superficial skin lesions. However, a reac- 
tion should be anticipated and the treatment stopped, because a long continued 
raying is not necessary when a soft tube is used. For epithelioma, while a 
hard tube is preferred, its exact quality should depend upon the duration, 
depth and extent of the individual lesion. It is well to remember what 
Bontgen has stated, namely, that other conditions being equal, "the intensity 
of the rays varies directly with the strength of the primary current, and the 
effect varies inversely as the square of the distance of the tube from the 
surface exposed." 

Phototherapy.- — While' the bactericidal properties of light have been 
appreciated for many years, it remained for Finsen of Copenhagen in 1S9G 
to make the first practical use of light-therapy. His method may briefly be 
defined as the concentration of a large number of chemical rays of light on a 
small area, at the same time exehiding the heat rays. Exsanquination of the 



TREATMENT 47 

part treated is necessary to ensure a deeper penetration of the light and to 
facilitate an acute inflammatory reaction. Compressors made of two quartz 
lenses, held together by a metal rim so as to leave space between, through 
which cold water constantly circulate* to prerent the heating of the lens are 
held ,n place by an attendant in Finse.rs Institute, but mechanical mean, 
are usually used by others to hold the compressors in place. Sunlight was 
used by Pinsen at first, hut later an an- light of 60 to 80 amperes and about 
.0 volts was condensed b - of lens. - ,1 m a metal tube which 

filled with distilled water to absorb the heat rays. The lenses are made of 
r "" ■ and the collecting lenses an- ; cm. in diameter. The rays are 

1 about six ii nthel,. An outer compart 

g cold water surrounds the whole apparatus, thus affording 
additional pretention from over-heating, lour patients ma] tted by 

this lamp by placing a system of condensers In each quadrant oi 

. i THE KKY-SCHEEREft CO.H.Y. 




1 ''■ -'-' I ,! kiatua Cor Phototherapy. 

For private work the small lamp devised by Fineen ai which end,,. 

-. but consists of one lent J dis- 

tance will [suffice. |„ this varietj the arc is so directed that the stronj 

*** ,i ' 11 ,lm " lv "" a» '»>< lens, and onlj 80 amperes and 55 rolbTare 
Decessary. 

..'" i,n "f 8 ,|M ' li - 1 " "'"-« '■''I perpendicularly upon the affected area 
w, " d ' " ,l,M l,r constantlj exsanquinateA Lenses of condei 1 ,„ ln . 

pressors must be clean, and to this end they should be washed with antiseptic 
solutions after each treatment. Air bubbles should not be allow,,] on the lem 
and .ho distilled water should be free from duel and dirt. Exposures < 



4S TREATMENT 

from fifteen minutes to two hours, and are repeated when the reaction has 
■subsided, which takes from one to two weeks. The reaction usually develops 
in six to twenty-four hours, and may vary from an erythema to a vesicular 
or bullous dermatitis, which can be readily distinguished from the normal 
skin. No necrosis of healthy tissue results, hence scarring is minimized. 
Pigmentations and dilatation of superficial blood-vessels may persist beyond 
the ordinary time for resolution. The painlessness of actual treatment and 
the smooth, neat scars are points to be recommended. 

There are disadvantages attached to this use of actinic rays. For extensive 
diseased areas it is sure to prove tedious and expensive, because only small 
areas averaging less than an inch in diameter can be treated at one time. The 
parts to be treated must be free from exudation and capable of exsanquina- 
tion. Mucous membranes are inaccessible. .Further, it must be remembered 
the penetration of the rays is limited. A thorough and careful technique 
is the best element of success in the treatment of those diseases which are 
responsive to this method. Among these may be mentioned lupus vulgaris, 
for which it is specially effective, and some cases of lupus erythematosus, alo- 
pecia areata, rosacea, eczema, vascular naevi, etc. For the special treatment 
•of these diseases the reader is referred to their respective headings in Part II 
of this book. 

In order to decrease the expense and to obtain more rapid results, a number 
of modifications of the Finsen apparatus have been put on the market. While 
not attempting to lessen the virtue of these machines for some few purposes, 
the writer must enter his protest against the comparison of their work with 
that of the original Finsen apparatus, because such records are not trustworthy 
nor scientific, and hinder rather than advance the cause of phototherapy. 
Chief among these modifications are the Lortet-Genoud and the London Hos- 
pital lamps, in which the source of light can be brought within two inches 
•of the surface which is to be treated. Exsanquination is produced by pressing 
the affected part firmly on the face of the front lens. An arc light, having 
carbon electrodes, an amperage of 10 to 12 and a voltage of 55, is used. Many 
smaller, less reliable and less expensive lamps are made. In these, iron and 
other metal electrodes, or the high-tension condenser spark, are used to pro- 
duce the ultra-violet rays in varying quantity. Naturally these have no 
penetrating power, since the rays are absorbed by the epidermis and hence 
are suitable for superficial skin lesions only. 

Becquerel Bays. — Under this term are included those phenomena noted 
by Becquerel in 1896 when he demonstrated the radiating power of uranium 
and some of its salts. Also, we include the emanations and radiations given 
off by radium, which the Curies separate:! together with polonium from pitch- 
blende. From radium and its salts are derived at least three varieties of rays, 
one has bactericidal and slightly penetrating properties, while the other two 
seem similar to the cathode and X-rays respectively. The action of radium, 
clinically and pathologically, is similar in many respects to the Rontgen rays. 
and hence its use in all of the diseases which have been treated by the latter 



TREATMENT 



49 



agency. Good results have been reported from radium-therapy in lupus 
vulgaris, epithelioma, eczema, pruritus and other diseases, but the small 
supply of relatively weak activity that lias been obtainable has effectually 
prevented scientific research. The writer has used specimens <>f 5,000, 7,000, 
20,000 and 200,000 radio-activity with results which will be mentioned in 
the following pag 

Inasmuch as recent investigations have proven that the so-called alpha 
,md the emanation- of radium are lost if the radium i> sealed in a con- 
tainer, it seems reasonable that tin- radium should be in such a form that 
irroundii)"- wall.- will not intercept the alpha rays or the emanations. 
To this end Lieber of New York has produced what be terms radium coat- 
radium being dissolved and a celluloid rod. or disc, or other instrument 
dipped in th.- solution. Tin- solvent then evaporates and leaves the coat- 
radium, and this i- then fixed with a layer of collodion. The collodion 
film permits the | if both alpha rays and emanation-. A hollow tube 

can be similarly coated. This plan enables • to apply radium to any part 

ile. 
Variable results have followed th.- use of this method, and only recently 
a number of cases have been reported which were much aggravated 
such treatment It would seem, inasmuch a- after their use no radium could 

be discovered on the rods by the most delics hat the particles had actu- 

ally lodged in the parts and caused a radium dermatitis. 



WAPPl ER EXC0.NEW YORK. 




■ Hum Electrode! for Administering the 
II igh In quency « Currents 



Hi.. ii Tension wi> Frequence Currents. — While these were first intro- 
duced into genera] therapeutics b\ D'Arsonval, Oudin that we owe our 



50 



TREATMENT 



initial knowledge of their use for diseases of the skin. There are a number 
of types known as high frequency currents of which the auto-condensation, 
the auto-conduction and the helioeoidal shunt of D'Arsonval, the resonator 
of Oudin and the hvperstatic of Piffard are the most important. The last two 
are chiefly used for skin lesions, and hence demand our attention. Of these 
the Piffard currents are less painful than the Oudin and their effect is nearly 
is great. Our personal experience has been largely with the Oudin resonator 
and as an adjunct to other measures in the treatment of seborrhcea, alopecia 
areata and prematura, acne, rosacea, urticaria, eczema, pruritus and the various 
parsesthesias, lichen planus, lupus vulgaris, varicose ulcers, etc., it should be 
regarded as indispensable. Splendid results have been achieved by its use in 
lupus erythematosus, and claims have been made for it in mam*- malignant 
skin diseases. These currents are administered through glass vacuum elec- 
trodes (see illustrations) which are held near the diseased area, but not in 
contact, for one to five minutes, daily or less often. 




Fig. 24. — Spiral-shaped Glass Vacuum Electrode for 
Administering the High Frequency Currents. 

The so-called unipolar X-ray tube, which is connected with the Oudin 
resonator, gives off X-rays when coming in contact with the surface, and has 
been of some service to the editor in cases of circumscribed eczema, and 
kindred disorders. For further clinical uses of these currents the reader is 
referred to the special diseases involved. 




TREATMENT 



51 



Vibration* and mechanical ""Ibbatohy massage by means of an elec- 
motor may be indicated for improving the circulation and assisting in the 






^sm=^ 



No. 3. 




►— 



TRIC CONTROLLER CO. 



So 1 



Unipolar X-ray Tubes with ami without Handles. 

ption of inflammatory induration. In cat leroderma, acne indu- 

rata, etc., massage of this typ ly [i>n\. The indications 

• oeral or loca] hand-i are the Bame as are found in genera] raedi- 




i 



Fio. 26 Electric Motor with Attachments tor Vibratory and Pneumo-masi 

and ( autery. 






52 CLASSIFICATION 

cine. The motor shown in the illustration has ■ attachments for cautery as 
well as for mechanical vibration and pneumo-massage, and hence is a conven- 
icnl type of apparatus. 

Other physical agents, such as radiant heat, freezing, liquid air, immer- 
sion in oxygen, etc., have been recommended for* ulcers of all types, lupus 
vulgaris, na?vus, warts, epithelioma and other diseases, but they cannot be said 
to possess any advantages over the more scientific methods heretofore men- 
tioned. 

CLASSIFICATION 

The test of any grouping of diseases is its practical utility for the pur- 
poses of study, diagnosis and treatment. It is not necessary that the classi- 
fication should be based upon one line of investigation, as pathology, etiology. 
etc^7~so long as it represents the greatest ensemble of facts and is in harmony- 
with scientific progress in its domain. 

Historical. — Attempts at systematic classification began with the regional, by Mer- 
curialis, in the latter part of the sixteenth century. He grouped skin diseases as they 
were situated on different regions of the body, without special regard for the nature of 
the lesions themselves. This arrangement seems to have sufficed for upward of a hundred 
and fifty years, when Turner divided cutaneous diseases into two general classes, — of 
the head, and of the body, — each with several divisions and subdivisions, intended to show 
the differences of the lesions as to shape and other qualities, while to eruptions of uncertain 
location he gave such names as syphilides, psorides, scrofulides, ephilides, etc., some of 
which continue in use at the present day. In 1776 Plenck made the first classification 
based on the objective character of the primary and secondary lesions, or the parts involved, 
as follows: (1) Macules, (2) Pustules, (3) Vesicles, (4) Bullae, (5) Papules, (6) Crusts. 
(7) Scales, ( 8 ) Callosities, ( 9 ) Excrescences, ( 10) Ulcers, ( 11 ) Wounds, ( 12 ) Cutaneous 
Insects, (13) Diseases of the Nails, ( 14) Diseases of the Hair. 

Willan, and, subsequently, Bateman, modified Plenck's classification, reducing the 
different classes to nine, as follows: Papules, Scales, Exanthemata, Bullae, Pustules, Vesicles. 
Tubercles, Macules, and Dermal Excrescences. Next in importance came the anatomical 
classification of Erasmus Wilson. He grouped skin diseases according to the part in which 
they originated, in four classes: (1) Diseases of the Derma, (2) Diseases of the Sudori- 
parous Glands, (3) Diseases of the Sebaceous Glands. ( 4)Diseases of Hair and hair follicles- 
A simple physiological plan of grouping cutaneous diseases was formulated by Barenspruns 
in three divisions: (1) Disturbances of Innervation, (2) Disturbances of Secretion. (3 ) 
Disturbances of Nutrition. 

Bazin and others of the French School sought, from time to time, to classify skin 
diseases according to their real or supposed causes. Bazin grouped all cutaneous diseases 
in three divisions: (1) Affections due to external causes, ( 2 ) Affections of internal origin, 
including those consecutive to some constitutional disorder, (3) Cutaneous deformities, 
congenital or acquired. In the effort to perfect this etiological system, a relation was 
assumed to exist between certain constitutional diseases and cutaneous eruptions, which 
had little foundation in fact. The increasing knowledge of the causes of skin lesions will 
probably permit, at no distant day, a practical classification of cutaneous diseases accord- 
ing to their principal etiological relations. Unna, Piffard and others have proposed classi- 
fications in this line, but without any general adoption by others. The classification of 
Hebra, published in 1845, marks the greatest advance in the method of grouping skin 
diseases. This plan classifies most diseases of the skin upon the evidences of their path- 



CLASSIFICATION 53 

ological anatomy. In one group only the etiological factors are recognised: in disi 
caused by parasites. Some groups contain diseases which are wholly different in nature 
and development, and not related in causation. Nevertheless. Hebra's method, with 
various modifications, is the one adopted by most dermati : the present time 

be best framework for practical study. 

Hebra's system groups cutaneous diseases in twelve classes: (, 1 ) Hyperemia- 
Anaemias, (3) Anomalie- ) Exudations, S Hemorrhages, (•) Hypertrophies 7 Atro- 
phia 10 1 Ulcerations, li Neuroses, I 12 Diet 
caused by parai 

A- illustrating tin- great endeavor towards scientific classification of diseases -hould 
be mentioned the radical system of Auspitsi 1881 . as elaborated by Branson, in i vv ~ 
wherein the nn'tUitrurnl seat of th - taken as the basis for classes, and the pad 

of diseases is shown by subdivisions into order-, tribes, families, genera, sad this 

arrangement of diseases, while undoubtedly -cicntihe. is tOO COmplei anil extended in 

detail to serve the student as idy of skin di -cases. 

Leaving oaf deration the Last plan of grouping cutaneous affections, 

it will be found that no one furnishes a systematic classification of sufficient 
scope uiii.ii is bannonioua In all it.- details. Nearly all have contributed 
in Bonn to build op a working system, modified in one way ami 

another by different authors, but looked upon by all as largely provisional in 
character, subject to revision with the advancement >>f knowledge concerning 
the origin and nature ( .f morbid processes in the cutai 

to the unavoidable defects of all systems of i ition, - e writers hi 

contented tl les in alphabetical order. Bear- 

in mind the objects of cIj A system which 

can meet those requirements and follow the line of the greatest progress in 
medical science would seem to be tin- most desirable under conditions. 

a\i modern medical research is chiefly i in the inv< a of 

the . it follow- that, in sucl m, prominence must !*• 

given to the stiological element. The d in this work 

therefore, a simple rearrangement, designed to show, -.. far as practicable, 
the -. without losing the value of the anatomico-patho- 

"i commonly in vogue. I i test of it- utility in b Further 

strength ecision to incorporate it here. To avoid a confusion of nan 

some di s eases are included in a class not warranted by their etiology. Thus 

the erythemas are kept together under the general bead of idiopathii 
tions. though some are. without question, neuropathic in relationship. Dis- 
tbe appendages of the -kin and new growths an* each grouped in a 

js by themselves, it would be impracticable, if not impossible, 

to otherwise place th ;nd meet the requirement! on 

for clinical purposes. 

Where the etiology of ;i disea-e. characterized by a mw growth, i- clear, 
it has been placed in a different group. Although there are placed 

in one or another class whose relationship thereto is doubtful. to 

the author expedient t<> temporarily waive the doubt rather than form a non- 

nifiable group. It is hoped the -cope of the classification will be found 
sufficiently elastic to permit the transference of a dinrmac from one group 



54 



CLASSIFICATION 



to another, as increasing knowledge of its pathogenesis may warrant. Lastly. 
it is expected that this method of grouping skin diseases will also, in a 
measure, classify and simplify treatment, especially for students and practi- 
tioners who are accustomed to individualize cases for the consecutive choice 
of therapeutic methods. 



Class I. — Diseases of the Cutaneous Appendages. 



A. Sweat Glands. 

Anidrosis 
Hyperidrosis 
Bromidrosis 
Uridrosis 
Chromidrosis 
Hematidrosis 
Phosphorescent sweat 
'"Hydrocystoma 
Miliaria (sudamina) 
Miliaria rubra 
Hidradenitis suppurativa 



Nature. 

Absence 01 sweat, 
Excessive sweat 
Abnormal odor of sweat 
Abnormal odor of sweat 
Abnormal color of sweat 
Abnormal color of sweat 
Abnormal color of sweat 
Retained sweat 
Retained sweat 
Inflammation 
Inflammation 



Pathogenesis. 

Neuropathic, etc. 
Neuropathic, etc. 
Parasitic, etc. 

Neuropathic, etc. 
Neuropathic, etc. 



Idiopathic 

Symptomatic 

Symptomatic 



B. Oil Glands. 

Asteatosis 
Seborrhcea sicca 
Seborrhcea oleosa 
Seborrhceic dermatitis 
Comedo 
Milium 

Steatoma (wen) 
Acne simplex 
Acne indurata 
Acne varioliformis 



Absence of secretion 
Excessive secretion 
Excessive secretion 
Excessive secretion 
Retained secretion 
Retained secretion 
Retained secretion 
Inflammation 
Inflammation 
Inflammation 



Deuteropathic 



Idiopathic 
Idiopathic 
Idiopathic 
Idiopathic 



C. Hair. 

Hypertrichosis 
Trichiasis 
Distichiasis 
Fragilitas crinium 
Trichorrhexis nodosa 
Monilethrix 
Lepothrix 
Tinea nodosa 
Piedra 
Canities 
Plica 
Alopecia 
Alopecia areata 
Folliculitis decalvans 
Dermatitis papillaris capillitii 
Conglomerate suppurative 
perifolliculitis 



Excessive growth 
Anomalous growth 
Anomalous growth 
Defective growth 
Defective growth 
Defective growth 
Defective growth 
Defective growth 
Nodular growth 
Atrophy of pigment 
Matted hair 
Loss of hair 
Loss of hair in patches 
Inflammation 
Inflammation and keloid 

Inflammation 



Neuropathic 



Symptomatic, etc. 
Neuropathic 
Neuropathic 
Parasitic- 
Parasitic 
Parasitic 
Neuropathic 
Idiopathic 



Parasitic, neuropathic 



CLASSIFICATION 



.).. 



Parasitic 



Class I. — Diseases of the Cutaneous Appendages -Continued. 

\). Nails. \n f Fn I 

Onychauxis Excessive growth 

Pterygium Excessive growth of nail fold 

Onychomyco Fungus growth 

Atrophia unguis Deficient nutrition 

on nail- Deficient nutrition 

Reedy nail- ient nutrition 

White nail- Deficient pigment 

Onychia Inflammation 

CLASS II. — Idiopathic Affections. 



Lentigo 
Chloai 

Erythema nmpJex 
Erythema neonatorum 
Erythema intei I 
Erythema traumaticnm 
Erj thema ealoricum 
Erythema Bcariatiniforme 
Erythema exudativum 
I hema multiforme 
Erythema iri- 

• ma DOdoi 

Derma ti til 
Dermatitis ami 
Derm on is 

1 lermatitii traumat 

gen-ray dermatitis 
I termatitis medican • 
l)ruj; erupt 

Illation ITU| ll !■ 

I termatitis vent 
tied erupt 
eruptions 



Hypertrophy of pigment 
Hypertrophy of pigment 

H\ penemic 

Hypenemic 

Hypenemic 

H\ penemic and pigmi ntary 

Hyperwniic 

Hyperamic 
Hj penemic 
Hj penemic 

Inflammator} 
[nflammal 
Inflammator} 
Inflai 

[nflammatory 

Inflammatory' 

Inflammal 

Inflammal 

Inflammatory 



Mirillc- 

ulea 

\ thema 

'. thema 

I thema 

thema 

Multiform 

N'odular 

Multiform 
Multiform 
Multiform 

Multiform 

Multiform 
Multiform 
Multiform 
.Multiform 
Multiform 



CLASS III. -Diathetic Affections. 



ma 
Paori 

I lermatitii exfoliativa 
Dermatitis exfoliatii 

ilcmii:i 

Dermatitis exfoliativa neo- 

natoruni 
Dcrmatil 
Multiple gangn 

. rene 
Diabetic g 
Dermatitis gangrem 

Ian turn 



Inflammatory 
[nflammatory 
Inflammator) 

Inflammatory 

Inflammator) 
Inflammatory 
Inflammator} 
Inflammator} 
[nflamma 

Inflammatory 



Multiple l< - 

scales 

< ■angrenoua uli 

i- ulcere 
renous uli 




56 



CLASSIFICATION 



Class III. — Diathetic Affections— Continued. 



Varicose ulcer 
Pityriasis rosea 
Lichen ruber 
Lichen planus 
Parakaratosis variegate 
Keratosis pilaris 
Keratosis senilis 
Keratosis palniaris et plan- 

taris 
Ichthyosis 

Sclerema neonatorum 
(Edema neonatorum 



Inflammatory 
Inflammatory 
Inflammatory 
Inflammatory 
Inflammatory 
Hypertrophic 
Hypertrophic 

Hypertrophic 
Hypertrophic 
Hypertrophic 
Hypertrophic 



Ulcers 

Patches, fine scales 

Papules and scales 

Flat papules 

Papules 

Papules 

Papules, warty growths 

Multiple 

Small and large scales 

Induration 

(Edema 



Class IV. — Neuropathic Affections. 



Nature. 



^Hyperesthesia 


Sensory disturbances 





Anaesthesia 


Sensory disturbances 





Paresthesia 


Sensory disturbances 






Dermatalgia 


Sensory disturbances 





Pruritus 


Sensory disturbances 


Excoriations 


Prurigo 


Senso-motor disturbances 


Papules 


Urticaria 


Senso-motor disturbances 


Wheals 


Urticaria pigmentosa 


Senso-motor disturbances 


Wheals and pigmenta- 
tion 
Swelling 


Angioneurotic oedema 


Senso-motor disturbances 


Purpura 


Vaso-motor disturbances 


Extravasations 


Rosacea ' 


Vaso-mocor disturbances 


Multiform 


Herpes 


Tropho-sensory disturbances 


Vesicles 


Herpes zoster 


Tropho-sensory disturbances 


Vesicles 


Impetigo herpetiformis 


Tropho-sensory disturbances 


Grouped pustules 


Dermatitis herpetiformis 


Tropho-sensory disturbances 


Multiform 


Dermatitis repens 


Tropho-sensory disturbances 


Multiform 


Pellagra 


Tropho-sensory disturbances 


Multiform 


Acrodynia 


Tropho-sensory disturbances 


Multiform 


Hydroa 


Vaso-motor disturbances 


Bullae 


Pompholyx 


Vaso-motor disturbances 


Vesicles 


Pemphigus 


Vaso-motor disturbances 


Bullae 


Scleroderma 


Vaso-motor disturbances 


Induration 


Leucoderma (vitiligo) 


Trophic disturbances 


White patches 


Atrophia senilis 


Trophic disturbances 


Pigmentations 


Atrophia maculosa et 






striate 


Trophic disturbances 


White lines and spots 


Kraurosis vulva? 


Trophic disturbances 


Local atrophy 


Glossy skin 


Trophic disturbances 


Smooth skin 


Perforating ulcer of 






the foot 


Trophic disturbances 


Ulcers 


Trophic ulcers 


Trophic disturbances 


Ulcers 


Symmetrical gangrene 






of the extremities 


Trophic disturbances 


Gangrene 


Ainhum 


Trophic disturbances 


Circular atrophy 


Syringomyelia 


Trophic disturbances 


Multiform 



I LASSIFICATION 



.), 



CLA88 V. — Parasitic Affections. 



A. Animal ORGANISMS 

• ie- 
Pediculosis corporis 

Pediculosis capitis 

l'i .|ji hi..-!- pubis 
Pulix irritant 

Pulix- penetmi 

( 'iiin-x leetulariua l bed 

Culix pipena (mosquito, 

gaai 

I.. I it u- aiitiinmali- 'hur- 
Lxodes rn-imi> 

Dermaoyasui avium 
1'ilaria medini 

iinia norm i 

itieercus oelluloaas outis 
Echinococcu* 

I )i'i lex fiilliciilnriiiii 



Purls Aff* 

Skin 
Skin 

.lp 
Hairy gurl 
Skin 
Skin 
Skin 

Skin 

Skin 
Skin 
Skin 

Sul.. 
Sul ii 
Sul.. 



Multiple lesions 
He m orr h agic points 

and cxioriat 

I !xeoristiona 

Excoriations and papules 

Win 

Vari 

Wheals 

\\ beak 

Wheals, papules 

Wheals 

Papules 

Tumon 

Tumoi 

Papules and pigmentation 



B. Vegetable < taOANUMS 

. tricbopytina ' ringworm I 

- 

'I'ii.. ilor 

ibrieata 

'lira-ma 

Dhobis itoh 

1 { I : t - 1 < > ■ ■ i \ I 

M> ringomj 1 1 

Pinto disease 

\. i inomj raeis ni the -kin 

M\ cetoma 

Impetigo simplex 

Impetigo I'liiitairioKa 

I i i hyina 

8) • ■ 
Paruneulm 

Cerbunculus 
Anthrax 

ection wounds 

Hhinosclirunia 
» trii-ntal boil 



Hair and -km 
Hair 

Skin 
Skin 
Skin 
Skin 
Skin 

Skin 

Skin and di< pel tissues 

Skin and deeper tissues 

Skin 

Skill 

Skin 

Hair follirlns 

foOidei and ad- 
jacent tissues 
Skin and deeper tissues 

Skin 
Skin 

Skill 



Yellow or 

«itli l.ranny 

Patches «itli a 

Papules in <-H. 

ipots 
Papulo-pustular 

1'atcln - 

i pots 

N... i 

Nod 
Pustules 

pustules 

pustulss 
Papules, pustules 

I'u-tiilc- and 
Multiple ali-<<— 

Multiform 

Pustules 

Tumor 

Tubercles, ul< • 



.->s 



CLASSIFICATION 



Class V.— Parasitic Affections— Continued. 



B. 



Phagedsena tropica 




Skin and deeper tissues 


Pustules, ulcers 


Elephantiasis 




Entire skin 


Enlargement 




Pathological Character. 


Process. 


Tuberculosis cutis orificialis 




New growth 


Infiltrating 


Tuberculosis verrucosa 




New growth 


Infiltrating 


Lupus vulgaris 




New growth 


Infiltrating 


Scrofuloderma 




New growth 


Infiltrating 


Lichen scrofulosus 




New growth 


Infiltrating 


Erythema induratum 




New growth 


Infiltrating 


Syphilis 




New growth 


Infiltrating 


Leprosy 




New growth 


Infiltrating 


Yaws 




New growth 


Infiltrating 


Equinia 




Inflammation 


Infiltrating 


Erysipelas 




Inflammation 


Infiltrating 


Erysipeloid 




Inflammation 


Infiltrating 


Class VI. 


— New Growths. 








Chief Structure 


General 






Involved. 


Character. 


Benign Connective 


Tissue 


Growths. 




Fibroma 




Connective tissue 


Benign 


Keloid 




Connective tissue 


Benign 


Cicatrix 




Connective tissue 


Benign 


Xanthoma 




Connective tissue 


Benign 


Xanthoma diabeticorum 




Connective tissue 


Benign 


Lipoma 




Fat tissue 


Benign 


Myoma 




Muscular ; issue 


Benign 


Neuroma 




Connective tissue 


Benign 


Angioma 








Nffivus vasculosus 




Blood-vessels 


Benign 


Hsematangioma 




Blood-vessels 


Benign 


Telangiectasis 




Blood-vessels 


Benign 


Angioma serpiginosum 




Blood-vessels 


Benign 


Angiokeratoma 




Blood-vessels, etc. 


Benign 


Lymphangioma 




Lymph vessels 


Benign 


Lymphangioma tuberosum 


multiplex Lymph vessels 


Benign 


Naevus pigmentosum 




Pigment, etc. 


Benign 


Acanthosis nigricans 




Papillary hypertrophy 


Benign 


Multiple tumor-like new growths 


Glandular tissue 


Benign 


Colloid degeneration of the 


skin 


Connective tissue 


Degenerative 


Lupus erythematosus 




Corium 


Infiltrating 


Myxcedema 




Skin and subcutaneous tissue 


Hypertrophic 


Acromegally 




Skin and subcutaneous tissue 


Hypertrophic 


Benign Epithelial Growths. 




Callositas 




Epidermis 


Hypertrophic 


Clavus 




Epidermis 


Hypertrophic- 


Cornu cutaneum 




Epidermis 


Hypertrophic 


Keratosis follicularis 




Epidermis 


Degenerative 


Verruca 




Epidermis, papilla? 


Hypertrophic 



CLASSIFICATION 



59 



Class VI.— New Growths— Con tin 



Papilloma cutis 

Molluscum contagiosum 

Multiple benign cystic epithelioma 

Adenoma 

ikeratoeis bucealis 



Papillae 
Epidermia 
Epithelium 
Connective 

Papilla- 



Hypertrophic 

Degenerative 

Benign 

Benign 

Benign 



C. Malignant Epithelial Growths. 



Epithelioma 

- disease 
Rodent ul 

Carcinoma CUtifi 



Epithelium 
Epithelium 

Epithelium 
C'orium 



Malignant 
Malignant 
Malignant 
Malignant 



D. Malignant l nvE Tiasi i. Growths. 

Sarcoma cuti* mm 

Mycosis I i ium 

Xeroderma pigmentosum Blood-vi • 

Van ( !onnective : 



Malignant 
Malignant 
Malignant 
Malignant 



PART II 

SPECIAL DISEASES 

CLASS I.— DISEASES OF THE CUTANEOUS APPENDAGES 



A. DISEASES OF THE SWEAT GLANDS 

The perspiratory function is largely under the control of the nervous 
system. Whether there is one sweat centre or many, peripheral sweat ganglia 
or none, nerve supply from the spinal cord or from the sympathetic, a watery 
product only, or oily secretion also, remain undetermined. The quality and 
quantity of sweat may vary considerably within the limits of health, from 
differences of habits of living, exercise, etc. When there is a persistent 
departure from these limits of quality and quantity, functional disturbances 
exist; when an anatomical change in the glands or ducts is found, organic- 
disease exists. 

ANIDROSIS 

Definition. — A disorder of the perspiratory apparatus, in which the 
sweat is absent or notably diminished in quantity. 

This condition is nearly always secondary in character and may be 
local or universal in extent. It is common in the areas affected by such 
diseases as ichthyosis, psoriasis, scleroderma, anaesthetic leprosy, some forms 
of eczema, neuralgia, and forms of paralysis. The polyuria of diabetes and 
albuminuria naturally diminish the perspiration. Injuries to nerve trunks 
may cause anidrosis, and it is present in many tropho-neuroses, until elec- 
trical irritability is restored. Finally, there are individuals who, from some 
idiosyncrasy, perspire little or none at all, under conditions of temperature, 
etc., which induce profuse perspiration in most people. Pruritis is often 
associated with anidrosis, and in such cases may be aggravated in the winter 
(pruritis hiemalis) or after a bath (bath pruritis). 

Partial anidrosis occasions no disturbance, and the generalized type may 
lead to no discomfort, except under influences which usually occasion free 
sweating. 

Treatment. — In purely symptomatic anidrosis the treatment should 
be directed to the primary disorder. Physiological treatment, by the use of 
water internally and externally, by cold sponging or shower baths, or com- 
bined with mechanical measures, as in the Turkish bath, shampooing and 



HYPEKIDRUS1> 61 

ge, tend to improve the innervation and nutrition of the skin and 

stimulate secretion. The introduction of vibratory mechanical massage has 

simplified the main object to be attained, stimulation. High frequency cur- 

bave ah en satisfactory for the same purpose. Idiopathic ani- 

- is rare and seldom marked enough to call for internal medication. See 

indications for Ahu, i. Lycopodium and Ntut motchata. 

HYPERIDROSIS 
(Idrosis, Sudatoria, Polydrotis, Hydr — / iting.) 

Definition. — A disorder of the perspiratory apparatus, in which the 
secretion is excessive. 

Miral or artificial warmth, a . libera 'ii of fluid-. 

. and other kindred itural pr active 

ration. In the abai stimuli, all 

due to diaeaee. Hyperidrosia ma era] or local, alight or - 

short duration or persistent. With I 

spiral ur in acute rheumatism, intermittent fever, phthisis 

and other wasting di- rned. They form a part 

of the symptomatology oi general practitioni 

The heal form- , ur in the axilla- and genital region, 

or on the palms of the hands and lually 

symmetrical, and on the irarmly o are apt to ated with 

offensive odor (bromidroeis), and. sometimes, with erythema, intertrig 
a. On the palms and soles th< tmmon in ) 

I pie, who suffer from cold extremities, due to :• rculation, ana 

more or leas ma i pidermis, 

which may be rivalled <>r flake off, leaving tin- part- tender to 

Bure. Hypertrophy of the outer layera of I f the palms, 

known aa tyh d by or 

of these surfaces. " 

ne lunli. or one-half of the bead supplied by the fifth i 
■ at of the disordi 

Et j im' Pat Whatever tin- underlying causes ■ 

no doubt that d( e medium through which 

byperidrosie is produced, whether in the nal Emulation of the 

cerebro-epina] rmpathetic >>r peripheral cl 

■ • ma\ be m th< mma 

and a the hrain: in the medulla, a- noted in ci jweat- 

e tumor- hare been found at the post-mortem; in the cord, from 
(rated refl om injury to peripheral nerves, aa rep 

by Weir Mitchell; from growl •■ kind which in nth the sym- 

pathetic. In women, disturbs] menstruation and hysteria may 

sive local sweating. In the Becond migraine tl ee perspi- 



62 BROMIDROSIS 

ration. Symmetrical hyperidrosis of the palms or soles may be congenital, or 
very rarely hereditary. Usually, such cases are moderate in degree. The 
physiological experiments of Claude Bernard demonstrating that paralysis of 
the sympathetic produced hyperidrosis, and of Brown-Sequard, that stimula- 
tion of sensory fibres gave like results, are of special interest in relation to 
the pathology of this disorder. There does not appear any abnormality in the 
size of the glands or in their lining epithelia, in cases of hyperidrosis. The 
prognosis varies with the cause and the degree in which it is removable. 

Treatment. — Eemedial measures should be directed to the causal con- 
ditions which underlie abnormal sweating. If local defects of circulation 
or innervation exist, physiological and mechanical means may be employed, such 
as friction, exercise, cold baths, etc. Applications of very hot water to the 
parts, once or twice daily, followed by a dusting powder of starch and boric 
acid in equal parts, is very often beneficial. If there is a tenderness from 
a laceration and friction, simple cerate or mutton tallow may be used in 
place of a dusting powder. Compound stearate of zinc powder is occasion- 
ally useful as a mechanical protective dressing. Salicylic acid, one part to 
nix of talcum powder, may sometimes be used with advantage. When in- 
volving the feet only, daily foot baths of a one per cent, solution of per- 
manganate of potash continued for two weeks, are beneficial. The editor 
has achieved splendid results with the application of high frequency cur- 
rents to the axillae twice a week, in cases limited to that region. Unna 
recommends one-half ounce of the tincture of belladonna in three ounces 
of eau de cologne for sweating of the hands. Most local treatment is, how- 
ever, palliative, and we must look to general physiological means to remedy 
corresponding errors and to pathogenetic treatment to effect a cure. There 
are nearly always plenty of indications for a prescription, either in the 
general condition, in the peculiarity of the local disturbances, or in both 
combined. See indications for Agaricus, Aurum mur., Ant. crud., Baryta 
carb., Cocculus, Conium, Fluoric acid, Graph., Hepar, Hypericum, Jabor- 
andi, Nat. sul., N. mur., Nit. acid, Pet., Puis., Rhodod., Sepia, Sil.. Sid. 
and Thuja. 

BROMIDROSIS 

(Osmidrosis, Fetid sweat.) 

Definition. — Offensive odor of perspiration, either when secreted, or 
acquired soon after. Like hyperidrosis (which is frequently present at the 
same time) bromidrosis may be general or partial. The local forms are 
most common and usually affect the feet only, though the axillae and 
about the genital region may be the seat of the disorder. In most cases the 
odor is not markedly offensive, and a few cases have been recorded where 
abnormal odors of the perspiration have been agreeable, such as that of 
pineapple, violets, etc. Bromidrosis of the feet is likely to be most dis- 



IKIDROSIS 



63 



gusting, and, in extreme cases, has been compared to the odor of putrid 
cheese, penetrating through stockings and shoes to such a degree as to 
make the victims shun indoor society. The associated hyperidrosis renders 
the feet sodden, often red at the border- onally blisters form, and 

the tenderness may temporarily incapacitate the patient for walking. 

Etiology and Pathology. — Young people are most subject to local 
bromidrosis of the feet. Occupations which require much standing seem 
to favor it. A few cases are due to emotional influences: some to ba< ; 
and in others the causes are obscure. In nearly all he foul odor 

is due to decomposition of the fatty acids of the sweat after secretion. The 
sweat-soaked epidermis probably furn table soil for the growth of 

bacteria. Mi. an be usually found a the toes unaffected with 

offensive sweating, similar in those found in cases of bromidrosi- 
were cultivated by Thin, ami these he callB Bacterium fcttidiun,. Prom 
the presence ganisma be attributes the decomposition and con- 

sequent odor. The m can be readily found by drying some of the 

sweat on a cover glass and staining ii with methyl violet. 

Tim a i \n \ i. — As hyperidrosis nearly alwa with bromidro- 

sis, the indications foT treatment irly the - for the former. 

Antiparasitics and deodorisers are most effective palliative api - and 

employed after bathing with hot wi flic acid, one part t<> 

thirty of Kay nun or cologne; part to four hundred 

of ro<e or cologne water; a one per cent solution of the per m aa \gana 
potash; and one pari of th< ■• of hydrogen to thn imong 

the beat Among dm odicationa for Hydrastis, Nitric and. Osmium, 

I'//.. I'lms.. Ehododci 5 3ul., Thuja and Zinc. 



URIDROSIS 
- ilur writ 

I)i F1NITXOX. A condition of the perspiration in which some of the con- 
stituents of the urine, chiefly urea, are present in excess. 

Normally, s small amount of una tod with the sweat Under 

certain abnormal conditions retion ii may become abundant enougl 

gather with other urinary salts, to leave a deposit upon tin- .-kin after evapora- 
tion of the fluid part of the sweai ; and. by decomposition, yield a inure o 
pronounced "dor of mine. Such instances maj occur in a person of ap- 
parent health: but most i mil from diseases of the kidney, Causing 

anemia; or from some profound states of the system, like the collapse in 
cholera and the sweating in articulomortis, when all equilibrium between 
i ions may be suspended. Probably in the pi if kidney impair- 

ment, the elimination of urinary constituents in t ; mav be vicarious 

in nature. Eryng. aquat. or Nit. acid may he useful in curable ca 



t»4 CHROMIDROSIS ' 

CHROMIDROSIS 

{Colored sweat.) 

Definition. — A disturbance in the function of perspiration in which 
the sweat is colored. 

The color has been attributed to the presence in the perspiratory exudate 
of the compounds of iron, indican, Prussian blue, cyanogen, phosphorus, 
hgematin, chromogen and bacteria. Cases of true chromidrosis are extremely 
rare. Pollitzer states that in some of the great dermatologieal clinics of 
Vienna, Paris, etc., no cases have ever been seen. Three forms of colored 
sweating have been described: — (1) From elimination of some substance 
taken into the system; (2) from neurotic disturbance of secretion; (3) 
from bacteria or false chromidrosis. Colored sweat due to elimination may 
be blue, green or red. In a case of blue chromidrosis, protosulphate of iron 
WalT found in the sweat. The patient had previously taken much iron. 
Green sweat is not uncommon in workers in copper, and may be profuse 
enough to stain the clothing. Eeddish sweat may come from the ingestion 
of iodine compounds. Excessive perspiration in the debilitated favors this 
elimination to the surface in some cases, doubtless where the substances 
have been given for medicinal purposes. Sudden changes in the color of the 
hair have been noted in cases of profuse sweating. 

In the neurotic form the color of the staining is some shade of brown. 
black or blue. It is usually symmetrically distributed, most often about 
the orbital region, especially the lower lid; other parts affected in order of 
frequency are the checks, forehead, side of the nose, more rarely the whole 
face, chest, abdomen, back of the hands, axilla?, groins and popliteal Bpace. 
It may appear rapidly or slowly, and change in color in like manner, while 
under immediate observation, or from one day to another. The secretion 
may form a granular deposit on the skin, which, in some cases, contains fat. 
This fact led Crocker to believe there were two sources of chromidros - 
the sudoriparous and the sebaceous. Although the deposit contains amor- 
phous granules, supposed to be indigo, chemical and other tests give only 
negative results. This disorder may disappear in a short lime, or persist 
for years. 

The form due to growths of bacteria occurs in mi - g ons, as the 
axilla? and genital, and is associated with a disease of the hair known as 
lepothrix. The red color is due to colonies of micro-organisms (bacterium 
prodigiosum), unconnected with the function of the sweat glands, and. there- 
fore, a false chromidrosis. 

Etiology and Pathology.— A very large per cent, of all cases of 
chromidrosis occurs in young unmarried women, mostly subject to some type 
of hysteria, and frequently sufferers from chronic constipation or uterine 
disturbance. There are good grounds for the belief that the disease is. at 
least primarily, a hysterical neurosis of the glands. The contributing rela- 



H.EMATIDROSIS— PHOSPHORESCENT SWEAT 65 

tion of constipation has been shown by relapses following a recurrence of 
the previously relieved constipation. The theory that indican is derived 
from the indol of the feces, and, on reaching the surface, is oxidized or 
changed by some ferment into indigo, is not proven. The deposit upon the 
skin is removed, with difficulty, with water; but is easily removed with 
either chloroform or glycerine; but, thus far, tests have not revealed its 
nature. The nature of the eliminative and the bacterial forms of chromi- 
drosis have been already mentioned. 

Diagnosis. — Barring imposture, there is no other condition which can 
easily be mistaken for chromidrosis. The hysterical element and the possi- 
bilities of accident and deceit should always be borne in mind. 

Prognosis and Treatment. — Eecovery is nearly certain; but the dura- 
tion and freedom from relapses depend on the success of causal treatment. 
Such treatment, by internal medication, may be required to cure constipa- 
tion, neurotic disorders, etc., local measures may be required for uterine 
disease, and antiparasitics, such as boric acid and resorcin lotions, chloroform 
or ether, for the parasitic form of the disorder. When the cause is an ac- 
cident of occupation or arises from drugs taken internally, avoidance of 
the cause is the only remedy. Conium, Merc, vivus, Dulcamara and Nux 
vomica should be studied. 

H^EMATIDROSIS 

(Epidrosis cruenta, Bloody sweat.) 

This rare condition occurs as the result of extravasation of blood into 
the coils and ducts of the sweat glands, where it mixes with the sweat as 
it escapes from the uninjured surface of the skin. It may follow as a rare 
effect of violent emotions, or be due to vicarious menstruation; and it has 
appeared in the new-born with fatal result. It is generally limited, the parts 
affected being the face, the hands, the feet, the umbilicus, etc. The amount 
of blood lost is small and the condition may be regarded as a symptom of 
hemophilia. See Crotalus as a possible remedy. 

PHOSPHORESCENT SWEAT 

This rare phenomenon has been attributed to a fish diet and presence of 
photophoric bacilli, but has also been found in the later stages of phthisis, 
and in miliaria. Beyernick found several species of photo-bacteria which 
were chiefly derived from fish. Phosphorescent breath, pus, semen and urine, 
when phosphorus is being taken internally, are not very rare, and phosphorus 
should be studied as a remedy for the first named cases. 



66 HYDROCYSTOMA— MILIARIA CRYSTALLINA 

HYDROCYSTOMA 

Definition. — A disorder of the perspiratory function in which the 
sweat accumulates in cysts, probably due to excessive perspiration, while 
the affected skin is exposed to artificial warmth and moisture. This is an 
affection almost exclusively limited to middle-aged women who expose their 
face, in washing over tubs, to warm moist air, and perspire freely. The 
disease is always worse in summer and may entirely disappear in winter. 
The lesions are nearly always confined to the face, and occur generally in 
discrete, round or ovoid, clear, shiny, tense vesicles, from a pin-head to 
pea size. They appear to be deep seated, but project above the surface, and 
resemble sago grains at their maturity. As they dry up they become whit- 
ish, like milium lesions. The larger ones may have a bluish tint, or a slight 
hyperaemia at the periphery. They dry up, without rupture, after lasting 
one— to three weeks, leaving the skin normal or lightly stained. The num- 
ber of vesicles may be small, or one to two hundred. At the most, the subjec- 
tive sensations are mild smarting or tension. The disease is of slight impor- 
tance, except as a facial blemish. Comedones or acne are frequently present. 

Diagnosis. — This affection might be mistaken for adenoma of the sweat 
glands, sudamina, pompholyx and possibly eczema. Adenoma has an alto- 
gether different history, and the contents are solid. Sudamina is an ac- 
cumulation of drops of sweat under the corneous layer only, and the small 
lesions rarely appear upon the face. Pompholyx occurs upon the palms 
of the hands or soles of the feet, and the vesico-bullae do not remain clear 
as in hydrocystoma. Absence of all signs of inflammation would serve to 
distinguish it from vesicular eczema. 

Prognosis.— The disease is only a disfigurement, unaffecting the gen- . 
eral health in any way. While it is almost certain to disappear spontaneously 
in winter, it is also apt to recur in summer from exposure to the same 
causes; and may become chronic from continued recurrence. 

Treatment. — If too unsightly the lesions can be punctured with a needle, 
and, after the escape of their contents, the parts may be bathed with hot 
water a minute or two. Without any local measures, resolution can be 
hastened by an indicated remedy, which should be prescribed on the totality 
of the symptoms. The editor has seen two cases respond to such treatment. 
See Ant. crud. 

MILIARIA CRYSTALLINA 

(Sudamina.) 

Definition. — An obstructive disorder of the perspiratory ducts, in 
which the sweat is retained at the orifice in the form of small clear vesi- 
cles, and usually appearing during the course of some febrile disease. 

Symptoms. — The vesicles are minute in size, usually discrete, and gen- 



MILIARIA RUBRA 67 

erally appear upon the trunk, abdomen or chest, but they may come else- 
where on the skin. They form rapidly in a few hours, rupture spontaneously 
in a few days, and soon leave the skin clear unless fresh crops appear. The 
color of the skin is unchanged about the lesions, winch may be few or 
many. They produce no subjective symptoms. This condition may follow 
the so called "critical" sweating of such diseases as typhoid fever, acute 
rheumatism and puerperal fever. 

Etiology and Pathology. — The presence of some acute systemic dis- 
turbance which diminishes both the nutrition of the skin and the perspira- 
tion is probably the first cause of miliaria. The retained or changed epithe- 
lium blocks up the orifice of the sweat ducts while the skin is dry, and a 
sudden resumption of sweat formation, unable to escape by the natural outlet, 
forms a sweat vesicle underneath the horny cells of the epidermis. 

Diagnosis. — The dewdrop-like vesicle, absence of local signs of in- 
flammation, and occurring in the course of a '"fever" cannot be mistaken 
for any other eruption. 

Treatment. — The nature of this affection suggests such remedies as 
Am. mur., Bryonia, Hydrocot., Merc. viv. and Urtica urens, but usually 
it is not treated specifically. The parts may be sponged with dilute alcohol 
and then a simple dusting powder applied. 

MILIARIA RUBRA 

(M. papulosa; M. vesiculosa; Lichen tropicus; Prickly heat; Sweat eczema.) 

Definition. — An acute obstructive disorder of the perspiratory ducts, 
either inflammatory or causing inflammation, with redness and itching. 

Symptoms. — It is a disease of hot weather, and attacks most often the 
stout, or persons too warmly clad and hence inclined to perspire freely. 
The eruption appears in the form of pin-point to pin-head sized, acuminate, 
bright red papules, often capped with tiny vesicles or pustules. These come 
suddenly and in great numbers, situated commonly on the chest, neck, back, 
abdomen, or arms, but may appear on the face or other regions. They are 
discrete but closely crowded together, and often there is more or less ery- 
thema. Sometimes the papules predominate, miliaria papulosa. The va- 
riety qf miliaria rubra called lichen tropicus or prickly heat is apt to be 
more papular in character. Nearly always, however, the vesicles are in 
much greater proportion, hence the name miliaria vesiculosa; after a fetv 
days the vesicles become opaque, and it is then miliaria alba. The sweat 
rash ("red gum" or strophulus) of infants is a form of miliaria rubra, due 
to over dressing, and in the very young often occurs on the side or part 
which rests against the mother during nursing, etc. The vesicles of miliaria 
do not rupture spontaneously, hence there is no weeping of the surface; if 
torn by scratching, a crust forms and is shed in a few days. The duration 
is about a week for a single outbreak, but during a hot spell fresh crops are 



68 MILIARIA RUBRA 

likely to prolong the attack. Pricking and itching sensations are often se- 
vere, and anything which stimnlates the circulation or promotes sweating 
aggravates the pruritus. The general health is unaffected and a -change of air 
or to cooler weather usually mitigates the attack at once. 

A few cases of chronic miliaria have been reported by English observ- 
ers, but it must be extremely rare. So-called miliary fever, which is also 
rare and comes in epidemics, has not appeared in the last few years. 

Etiology and Pathology. — The apparent causes have been stated in 
defining the disease; i.e., warm weather, obesity, excess of clothing and free 
perspiration. Occasionally rapid alternations of temperature, either from 
cold to hot, or from hot to cold, is an exciting factor. Irritating quality of 
the clothing, such as coarse flannels, or clothing made irritating by uncleanli- 
ness, may contribute to cause an outbreak. Acrid or other irritating prop- 
erties of the sweat, as well as injudicious eating and drinking, have been 
noted as causal factors. 

A certain amount of local vasomotor disturbance enters into the pathology 
of miliaria; in most eases this is probably secondary in occurrence, and in 
the nature of a hyperemia of the corium with some serous transudation 
into the epidermis, aiding to prolong the disorder. But it is entirely pos- 
sible that the congestion may be primary, and that the watery effusion from 
the blood, together with the perspiration, interferes with the cornification 
of the cells of the epidermis, and which may by soakage swell up and oc- 
clude the sweat ducts during a temporary subsidence of the active perspira- 
tion. The renewed flow of sweat meets the obstruction in the duct and 
accumulates by dilating the canal in the epidermis, ending in rupture and 
the formation of the miliary lesions characteristic of this disorder. It is 
likely, therefore, in a pathological sense that there are two kinds of miliaria 
rubra. One in which the hyperemia is secondary to the sweat obstruction 
— a result of the local disturbance; the other in -which the hyperemia is pri- 
mary, and causes or aids in causing the sweat obstruction. In either way the 
process is to be looked upon more as a sweat erythema than as a sweat eczema. 

Diagnosis.' — The association of miliaria rubra with sweating during 
the prevalence of warm weather and the absence of constitutional symptoms 
will generally suffice to distinguish it from the eruption of other diseases. 
In vesicular eczema the vesicles rupture and there is oozing and crusting 
with a tendency to persist; whereas, miliary vesicles do not rupture, and the 
individual eruption is transitory. It may be known from the eruptive 
fevers by the absence of constitutional and other symptoms typical of those 
diseases. The occasional association of miliaria with the cutaneous manifes- 
tations of infectious diseases is to be borne in mind in suspicious cases. 

Treatment. — Simple dusting powders or cooling lotions of one part 
of vinegar or alcohol to four parts of water will usually suffice to relieve 
miliaria after the exciting cause is removed. Attention to one's habits, cloth- 
ing, etc., will prevent a recurrence. See indications for Am. mur.. Ant. cmd.. 
Bell., Bry., Jaborandi and Hydrocot. 



HYDRADENITIS SUPPURATIVA ,i; ' 

HYDRADENITIS SUPPURATIVA 

Definition. — An inflammation of the sweat glands attended with sup- 
puration and resulting in the formation of a scar. 

This disease is sometimes described as a form of boil, but as Pollitzer 
has pointed out, there is no real ground for such association. The lesion 
begins as a small, deeply seated nodule, covered by the unchanged and freely 
movable skin. In the course of two weeks it slowly enlarges to the size of 
a pea and becomes slightly painful, and the skin over it red. If incised at 
this time a drop of pus escapes. Untouched for a few days longer, the cen- 
tre of the lesion becomes yellow, and soon discharges a few drops of pus 
from one or more minute openings. A little blood may be mixed with the 
pus, and in drying forms a brownish adherent crust which drops off a 
few days later, leaving a reddish, pigmented spot at the site of the tumor 
and ultimately a small cicatrix. The lesions may be few or many. Often 
it occurs singly in the axilla?, on arms, nipple, and genital regions. The dis- 
ease may develop on any part of the skin, but, when multiple, it more com- 
monly involves the face, neck, extremities, or trunk. 

Etiology and Pathology. — Little is known as to the causes of the dis- 
ease. It is most common in young adults and those who perspire excessively. 
Parasites, cold, uncleanliness, pruritus, scrofula, cachexia, neurasthenia and 
hyperidrosis have been named as causes. Whether the pathological process 
is due to infection or to the elimination of some irritating or toxic agent by 
the gland is not known. The acute parenchymatous inflammation starts 
in the sweat gland and involves the immediately surrounding tissue, going 
on to the suppurative stage with a final destruction of the affected glands. 

Diagnosis. — Boils differ from hydradenitis in that they are attended with 
more severe inflammation, tensive pain, followed by prominent elevation of 
the skin, and end with the discharge of a central core. 

In acne, there is an absence of nodules; the lesions are papules and 
pustules, involve the hair follicles, and are often associated with comedones. 
Cachectic acne is a symptom of struma, and the lesions consist of papules 
(lichen scrofulosum) and distinct pustules with a reddish areola. The 
nodular sypliilide, which, according to Bazin, develops in the sweat glands, 
differs from hydradenitis suppurativa by the rapid softening of the central 
part of the nodule and the formation of a characteristic s} r philitic ulcer. 
Ringworm of the beard with nodular swellings may be distinguished by 
the lesions involving the hairs, and by the microscope showing the presence 
of the fungus of that disease. 

Prognosis. — Uncomplicated suppurative hydradenitis is followed by ulti- 
mate recovery. Engrafted on some previous disease which lowers the vital- 
ity, it may prove a serious complication. 

Treatment. — When the lesions are located on the face or neck, one 
object of treatment is to limit the resulting scar as much as possible. To 
this end each nodule should be promptly incised, cleansed and occasionally 






70 ASTEATOSIS— SEBORRHCEA 

rubbed with three per cent, creolin in glycerine. Dietetic and general hy- 
gienic measures vie with the pathogenetic to effect a cure. See indications 
for Ant. crud., Ant. tart., Ars. ~brom., Cal. sul., Juglans reg. and Nat. mur. 

B. DISEASES OF THE SEBACEOUS GLANDS 

Under this head will be found only affections which involve the oil 
glands of the skin, in part functional and in part inflammatory or organic. 
To what extent the oil glands and other tissues are also involved it is not 
always possible to say. The primary or chief disturbance, however, is in- 
dicated by the heading. 

ASTEATOSIS 

Definition. — A condition of the skin in which there is partial or 
absolute deficiency of the sebaceous secretion in one or more regions of the 
body. 

It is usually symptomatic of other affections, such as psoriasis, ichthyosis, 
lepra, etc. Idiopathic cases are rare. Palliative treatment consists of frequent 
baths and inunctions with oil. As in anidrosis vibratory massage and the high 
frequency electric currents have proven valuable. Among internal remedies 
see indications for Alumina, Coco and Lycopodium. 

SEBORRHCEA 

(Seborrhagia; Steatorrhcea; Stearrhcea; Sebaceous flux; Dandruff, etc.) 

Definition. — A functional disorder of the sebaceous glands character- 
ized by an abnormal secretion, in the form of oil, crusts or scales, as it accu- 
mulates on the surface of the skin. 

The disease occurs in two forms according to the condition of the product : 
when this is dry it is termed seborrlicea sicca, when oily so as to give a 
greasy appearance to the surface affected it is called seborrlicea oleosa. Oc- 
casionally the two forms may exist in the same person at one time. Either 
form may be slight and of short duration, or wider spread and persistent, 
lasting for years. The disease may occur on any part of the body where 
there are oil glands. The most common sites are the face, scalp, genital 
region, back between the shoulders and in front of the chest. It may oc- 
cur at any age, and the patient may exhibit any degree of health from 
anaemia to plethora. Usually the skin itself is anaemic, but may be con- 
gested or inflamed, with consequent redness and some degree of pruritus. 

Seborrhcea Sicca. — This is the most common form, and occurs most 
frequently upon the scalp, where it is designated as "dandruff." Unna 
states, that when seborrhcea is found elsewhere on the surface, some evi- 
dence past or present will be almost invariably found of its existence on the 
scalp. It is best studied according to location. 



SEBORRHEA 



71 



Seborrhcea capitis occurring in infancy is popularly known as crusta 
lactea, or "milk crust." This may originate from the dried vernix caseosa 
remaining on the vertex of the new born, or it may begin on scalps which 
have been well or too much cleansed. In the adult the disease is usually 
symmetrical, and shows itself by the formation of yellowish white greasy 
plates of dried sebaceous matter, somewhat adherent to the surface and 
penetrated by some of the hairs; or in smaller particles which are freely 
shed from the surface and lodge upon the clothing over the shoulders of 
the person whose scalp is affected. The disease may be circumscribed, or 
occur in more or less diffused patches, on which occasionally the accumula- 
tions may paste the hairs to the part involved; often there is a fringe 
about the brow extending on to the scalp from the borders of the hair, on 
which the scales are apt to be persistent. Sometimes the whole scalp is 
uniformly involved, but in nearly all cases which last for any length the ver- 
tex and crown of the head is affected. In the latter regions the effect 
of the disease in producing premature baldness is most often seen. The 
hairs deprived of their natural lubricant become dry and fall from their 
follicles, and, if the causal seborrhcea be not arrested in time, atrophy 
of the hair follicles follows, and the loss of hair becomes permanent. For- 
tunately the alopecia is generally symmetrical, occasionally it is asymmetrical 
and the loss of the piliary adornment more unsightly. In infancy the loss 
of hair is always temporary. The surface of the scalp affected is usually 
anaemic and pale grey in color; occasionally dark red, circular, moist 
patches may be found at different points. These are often due to excoria- 
tions with the finger nails, made in the attempt to relieve the slight itching 
by scratching. More rarely there is a diffused hypersemia with more or 
less epithelial desquamation added to the sebaceous accumulations, pityriasis 
simplex. Still another type of cases occurs associated with eczematous in- 
flammation, and known as seborrheal eczema or seborrhceic dermatitis. 
which will be considered under a separate head. The bearded portion of 
the face, the eyebrows and the hairy portion of the pubic region may be 
involved in a similar way as the scalp. 

Seborrhcea faciei most often occurs at the period of puberty in both 
sexes. The sebaceous matter is usually adherent to the surface in the form 
of dirty yellow to yellowish black, rather thick plates, sometimes exten- 
sive enough to present a mask-like appearance. The accumulations are fre- 
quently most marked upon the nose, and in a less degree upon the cheeks, 
forehead, eyelids, and chin. If the secretions are removed they rapidly 
reform as a rule. The recently cleansed skin affected by the disease is 
commonly found pale or slightly reddened, and shows the patulous openings 
of the ducts of the sebaceous glands into which stalactite-like formations 
on the under part of the crusts have fitted. 

Seborrhcea corporis occurs in circumscribed, round, or irregularly de- 
fined patches, singly or in groups; owing to some degree of friction from 
the clothing, the disease is not so pronounced as in other forms, and is 



72 SEBORRHGEA 

chiefly limited to the sternal, clavicular, scapular and -umbilical regions. 
The primary lesions may have a papular appearance, seborrhcea papulosa, 
and form patches by peripheral extension and coalescence, followed by 
clearing in the centre ; thus forming imperfect circinate rings and resembling 
ringworm lesions. Seborrhceic papules are not uncommon in congestive 
forms of seborrhcea of the back of the neck, from extension downward from 
the scalp. In men the disorder is most often seen upon or near the 
sternum, where it appears in slightly, reddened, roundish patches, partly 
covered with dry, greasy, yellowish scales; about the shoulders and back 
friction from the clothing may keep the patches quite free of scales. In the 
umbilical region the secretion is apt to decompose and give rise to a fetid 
odor; sometimes producing an eczematous inflammation with a sero-purulent 
discharge from the umbilicus. 

Seborrhcea may become generalized by extension over the surface; such 
cases are not common. A few cases of seborrhcea generalis have been reported 
under Pityriasis Tabescentium, Cutis Testaeea, Ichthyosis Sebacea. Whether 
occurring in infants or adults, there is always secondary marasmus. As 
observed in infancy, the skin is covered with a greasy layer, and underneath 
appears a glassy brown or reddish-brown color. If the seborrhceic covering 
is removed it rapidly reforms. In the stiffened skin painful cracks form, 
interfere with nursing or feeding, and, consequently, with nutrition. When 
the disease occurs in adults there are usually found dirty, blackish crusts 
which separate largely in the process of desquamation on lines corresponding 
to the natural folds of the skin. 

Seborrhcea genitalium may be of the dry or oily form. About the 
external genitals and perineum it is commonly of the oily variety at first. 
Later the secondary irritation is likely to change the clinical aspect to an 
eczematoid form. In women semi-solid accumulations may occur about 
the clitoris, vestibulum and labia. In men similar accumulations may occur 
behind the corona glandis, or further extended if a redundant or tight pre- 
puce exists. Sometimes a ring of hardened and retained smegma gives 
rise to reflex disturbances of various kinds, especially in the young. Females, 
while less liable to reflex disorders, are more subject, from the larger and 
more exposed surface and consequently increased liability to decomposition 
of the secretion to superficial irritations or even ulcerations. These might 
be mistaken for chancroid lesions, or in cases of suspicion of criminal at- 
tempts in young girls might become of medico-legal importance. 

Seborrhcea Oleosa. — This form is characterized bj r an excessive secre- 
tion of an oily fluid which may occur upon any part of the surface, but is 
most common on the scalp and on the middle third of the face. In the 
latter situation it is more frequently seen than dry seborrhcea, especially 
on and about the nose, naso-labial fold and corners of the mouth. In elderly 
people the disorder in this situation is said to be associated with the develop- 
ment of epithelioma. On the scalp the oily secretion is seen to cover both 
the skin and the hairs, and, when baldness exists, gives the surface a pol- 









^^^H 


■ 




; 4 




b 


'fl 






V$:$ 








I • 





Fig. 27.— SEBORRHQEIC DERMATITIS 



CHRONIC, GENERALIZED, PSORIASIFORM VARIETY 

Patient, girl of seventeen. Macular and papular lesions, abundant on trunk, 
less numerous on extremities and face. Yellowish (honey colored), greasy crusts 
partly covered many of the lesions. Duration, three years. Symptoms, general 
loss of vitality; yellow coating on tongue and yellowish exudations and crusts; 
moderate pruritus, worse in warm room, better in open air. Cured with kali sylph. 
sixth decimal without local treatment. 




Fig. 28.— SEBORRHEIC DERMATITIS 



CHRONIC, ERYTHEMATOUS, EXFOLIATING VARIETY 

Patient, woman, aged thirty-six, of good general health. The symmetrical 
patch on nose and cheeks resembled lupus erythematosus, but the crusts were not 
uniformly dry or adherent and at sections of the margin were fatty in character. 
More typical seborrhceic lesions were found on the eyebrows and scalp. Duration, 
twelve years. Symptoms, few, slight variable itching or burning, aggravated by 
warmth and washing. Cured with sulphur sixth decimal and the local aid of resorcin 
five per cent, ointment to prevent reaccumulation of crusts. 



SEBORRHEIC DERMATITIS '■> 

ished appearance. This secretion may solidify in masses, as described in 
dry seborrhoea, but the oily condition of the .surface usually remains. In 
pronounced form, free drops of oil can be frequently wiped from the surface, 
and the ducts may be seen to be patulous or stopped with comedones, or 
the dust floating in the air may become attached to the oily matter and give 
the surface a dark or dirty appearance. If the ail'ected surface be at the ,-:ann 
time reddened and symmetrically distributed on the face, it might be mis- 
taken for seborrhoea congestiva, a designation given by Hebra to an early 
stage of lupus erythematosus, in which the ducts of the oil glands are plugged 
with adherent scales. The tenacious character of the latter serves to deter- 
mine the existence of that disease. The skin in seborrhoea is usually cool to 
the touch, but may be either reddened or pale. In the negro race a free 
oily secretion is more physiological, and may give to the exposed parts of 
the skin a pretty constant shiny look, without further evidence of the dis- 
order appearing. 

SEBORRHCEIC DERMATITIS 

A condition in which seborrhoea and an eczematous type of inflammation 
involve the same surface of the skin, has been described under different 
heads by several authors. Unna first described the disease as eczema sebor- 
rhoicum, taking the ground also that seborrhoea was often, or in part, due 
to an oily secretion from the oil glands. This claim has not been fully 
confirmed by later investigations by other observers. The disorder has 
been named Sudolorrhoea by Piffard, apparently for the same reason that 
Brocq named it "oily hyperidrosis." More recently the disease has been 
given the qualifying term of dermatitis, and, inasmuch as the inflammatory 
part is secondary to the seborrhoea, this seems the more appropriate name. 
The disorder nearly always begins as a seborrhoea of the scalp, which may 
have existed for some time; or, rarely, its starting point may be the axilla, 
genito-crural region, front of chest, and still more rarely on other parts of 
the trunk or extremities. Exceptionally, the distribution may become uni- 
versal. Seborrhceal dermatitis spreads slowly as a rule, and by peripheral 
extension, but may remain stationary for a long time; suddenly become active 
and spread in a uniform way, or more often appear at some new and distant 
point and pursue an irregular course. The lesions may be few or many; 
discrete, near together, or coalesce and form various shaped patches. The 
simplest form presents a more or less diffused scaliness, the color of the 
affected skin tinged with yellow or slightly reddened. The scales may be 
abundant enough to form adherent masses, varying in color and consistency 
with the character of the sebaceous secretion, from a dry gre) r ish white to 
a rather soft yellowish brown. This form is little more than a seborrhoea, 
with mild symptoms of irritation, such as itching, burning, etc. 

In the second degree, superficial macules with sharply defined borders 
are seen. They vary in shape, though often round or oval; in color, from 



74 SEBORRHEIC DERMATITIS 

a yellowish-pink to a pronounced red. There may be found also near by 
reddish papules scattered about or aggregated together. lit women past 
the middle period of life it is not uncommon, to see a diffused redness of the 
whole or part of the scalp, extending down upon the neck or about the ears, 
with papular elevations here and there near the periphery. In such cases 
scales usually form abundantly and uniformly over the part of the scalp 
involved. 

Macular and papular lesions may, by peripheral extension and concurrent 
involution centrally, form circinate, concentric, or in union with similarly 
involuting lesions, band-like forms of efflorescence. The formation of scales 
may be scanty or abundant, and exhibit the same character as in the simple 
variety of the disease. When the scales are dry and whitish and sparsely 
distributed over the lesions, there may be a resemblance to the lesions of 
psoriasis, from which the scales have been partly removed, seborrhea psoria- 
sifgxjnis. So, also, may the thickly crusted lesions of similar shape to those 
of psoriasis closely simulate the latter disease. 

In other cases the surface of the lesions may be moist from admixture 
of sebaceous secretion, sweat arfct serous exudation. Sometimes there is 
a distinctly catarrhal discharge, which may dry into crusts; thus presenting 
some of the features of an eczema, seborrhea eczemaformis. 

In a third degree the inflammatory type of the disease is more pro- 
nounced, the skin is more deeply engorged and reddened, the greasy catar- 
rhal discharge more abundant, and the itching sufficiently marked to induce 
scratching. 

The squamous form of seborrhceic dermatitis is most common, but all 
degrees of the disease may commingle at the same time, or appear in slow 
or rapid succession upon the same person. 

On the scalp the disease may involve the whole surface (most often in 
women), or be chiefly limited to the vertex or occiput. There is commonly 
a greyish-white desquamation from a pale red and dry skin, pityriasis capitis. 
Sometimes the scales form in masses about the hairs, and when loosened 
appear as if strung upon individual hairs. The hair itself is lustreless and 
after a time becomes thinned out, alopecia pityrodes. Moist lesions may 
occur on the scalp; they are usually round or oval, sharply defined, yellowish 
red, and may become crusted over. At the margins of the forehead and occi- 
put the lesion may appear as well-defined curved bands or lines covered with 
scales or fatty crusts. Over the brow of these crusty circlets, "corona sebor- 
rheica," are frequently seen. When the process extends from the scalp down- 
wards it is more apt to spread down the forehead, temples and back of the 
neck, where there is produced a distinct redness of the affected surface, 
partially covered with fatty scales and occasionally moist lesions appear. The 
disease not infrequently appears upon the face without immediate extension 
from the scalp. The middle third of the face is most often affected, some- 
times the butterfly distribution is seen over the nose and outward upon the 
oheeks similar to lupus erythematosus. The area of reddened skin is quite 



SKBORRHCEIC DERMATITIS < » 

sharply defined; often heavily crusted, especially on and about the nose and 
eyebrows. Other parts may be reddened and greasy, and moist spots may be 
seen here and there; upon the cheeks yellow or reddish macules with less 
abundant scales are the most common lesions. The back of the ears may 
be affected with the moist or dry forms of the disease, and fissures may com- 
plicate the process. If the auditory canal is affected the meatus may become 
filled with the fatty accumulations and the hearing impaired. One case of 
total one-sided deafness from this cause has come under the author's obser- 
vation. 

The colored borders of the lips are rarely attacked, and in two cases under 
observation were secondary to the disease elsewhere. The lips affected are 
uncomfortably dry and stiff, from the presence of darkish crusts, which 
tend to separate and form superficial cracks into the moist denuded surface 
exposed. When the crusts are removed or shed, the lips very soon become 
dry and shiny, and the process of crusting is repeated. 

When involving the eyelids and the outer and inner angles of the eyes, 
it has been noted by the editor that the secretions of the eyes, especially 
when there is marginal trouble to complicate, serve to prolong the condition 
markedly; hence it is that seborrhceic dermatitis in this region is often of 
the pigmented, scaly, chronic type. 

In the axiila and genito-crural regions the disease usually occurs in red 
macular spots of various size, which are confined to those regions, show little 
crusting, owing to the presence of moisture; but if the disease spreads away 
from those regions, as it is apt to do by peripheral curve-like growth, scales 
and crusts form. Thus from the axillae the lesions may extend forward on 
to the border of the chest, or backward on to the scaprdar region; or from 
the inguinal region down upon the thighs and buttocks, over the external 
genitals and back upon the perineum. Where two surfaces of affected skin 
come in contact it may simulate an intertrigo. 

On the trunk the disease begins, as a rule, with small papules tipped with 
a smaller scale, or as macules more or less covered with scales; on the chest 
and back the papular form, seborrhoea papulosa, is most common. If iso- 
lated, they spread by peripheral growth, or if near together papules may coal- 
esce. In either case, a central evolution, sometimes including a portion of 
the circumference of a lesion, together with the mode of growth and mer- 
gence with other lesions, may result in figurate shapes of various degrees. 
The borders are sharply defined, scaly and often show raw exuding points. 
Thin, fatty scales may nearly always be found on the old portion of the 
patches. On other parts of the body and on the extremities the disease is 
of least frequent occurrence, the lesions are more macular in type, round 
or oval in shape, and less likely to merge together to form irregular patches. 
They may be bright red or have a . yellowish hue, with slight scaliness or 
thickly covered with fatty crusts, about which a reddish border may be seen. 
Solid papular lesions are sometimes present with the same variations in 
scaliness or crusting as the macular form. In both forms the crust mav 



76 SEBORRHEIC DERMATITIS 

cover a moist or a dry base; they may remain roundish or change to coin-like, 
circinate or irregular shapes. 

Between the -fingers the disease may exhibit features similar to those 
seen in the axillae or groin. Lastly, it is well to note that seborrhoeic derma- 
titis may co-exist with other cutaneous diseases, such as the syphilides, 
rosacea, sycosis and acne. 

Etiology and Pathology. — Certain constitutional conditions of the 
system are said to predispose to seborrhoea, such as syphilis, gout, chlorosis, 
struma, chronic alcoholism, debility following fevers and malnutrition. Dis- 
orders of menstruation, of digestion, obstinate constipation, sedentary hab- 
its, excessive use of tobacco, and, in men, the wearing of stiff, heavy hats are 
causal factors. The fact that the disease occurs at all ages, and, in most 
eases, in persons of good or robust health, indicates that there must be a more 
direct cause than those enumerated. The not uncommon neglect of the 
scaip no doubt is often the first external beginning of a seborrhoeic dermatitis. 
Upon a surface where sebum and epithelial matters have accumulated to 
some extent, it is not unreasonable to suppose that micro-organisms may 
often find a suitable medium for growth. The clinical behavior of the disease 
favors this solution, as does the investigation of Taenzer, who isolated some 
eighty varieties of bacteria from the lesions of seborrhceal eczema. That the 
several forms of the disease occur in persons affected with some disturbance 
of health proves, as Morris has said, that, like other morbid processes, it 
flourishes best in a congenial soil. 

It has been thoroughly proven by TJnna, Brooke and others that the 
seborrhoeic process has a marked influence on the development and course 
of such diseases as acne, rosacea, eczema, psoriasis and syphilis. Despite the 
investigations of Sabouraud, who claims that seborrhoea is due to a micro- 
bacillus, there has been no satisfactory demonstration of the parasitic nature 
of seborrhoea or seborrhoeic dermatitis. 

Pathologically, seborrhoea is an epidermic disease showing an over-produc- 
tion of normal sebum and a dilatation of the sebaceous gland-duct openings. 
Normally, the sebum is produced by a fatty degeneration of the epithelia 
lining the pockets of the sebaceous glands. In the simple forms of sebor- 
rhoea there are changes in the secretion, as to quantity, fluidity, inspissation 
and sometimes a consequent tendency to decompose and give rise to super- 
ficial inflammation. Such results <?an be produced artificially by external 
changes of temperature, friction, etc. In the severer forms there is added 
some degree of inflammation of the glandular or peri-glandular tissues. 
Therefore, the latter are to be viewed as forms of dermatitis, due to the 
irritation of external agents (micro-organisms, etc.), in the absence of a 
normal resistance of the epidermis, resulting from some local or general 
condition. 

Diagnosis. — The distinctive features of seborrhoea are its starting first 
upon the scalp in the great majority of cases; its tendency to spread from 
thence downward; the greasy nature of the secretions: and. when there is 




Fig. 29 — SEBORRHEIC DERMATITIS 

CHRONIC, MACULAR, CIRCINATE VARIETY 

The subject, a young woman in fair health. Location of lesions depicted and 
similar patches on right leg. Duration, one year More active lesions in groins of 
longer duration and seborrhcea of scalp for several years. Symptoms, pale face, 
torpidity, itching, sensation, worse morning and evening, while sitting, better in 
open air. Cured with sepia sixth decimal and daily applications of six per cent, 
alcoholic solution of resorcin. 




Fig. 30.— SEBORRHEIC DERMATITIS 

CHRONIC, ERYTHEMATO-VESICULAR, CRUSTED, ECZEMATOTJS VARIETY 

Patient is a man aged sixty. Extensive seborrhoea of the face and scalp exists. 
The inflammation on the legs above the knees is distinctly seborrhoeic with fatty 
exudation, slight infiltration and sharply defined borders; below the knees distinctly 
eczematous, with considerable infiltration, more pronounced in the right leg. Dura- 
tion two years. Cured under the internal use of sulphur, two hundredth, followed 
by graphites in the same potency and the local application of sterilized oil. 



SEBORRHEIC DERMATITIS 



77 



congestion or inflammation present, the history of a primary seborrhea. The 
characteristic greasiness of the skin and hair in seborrhcea oleosa makes easy 
the diagnosis of that form. The dry and inflammatory form might be mis- 
taken for eczema, psoriasis, ringworm, impetigo contagiosa, syphilis and 
lupus erythematosus. 

Eczema may co-exist with seborrhcea, especially in infantile eczema of 
the scalp. In eczema the early presence of ill-defined redness, infiltration, 
or a discharge from the skin, darker crusts, and marked sensations of itching, 
will, as a rule, clearly distinguish that disease. In squamous forms of eczema 
the scales are not greasy, or as freely shed from the surface as in seborrhcea 
sicca or seborrhoeic dermatitis. 

Psoriasis commonly begins upon the extensor surfaces, and if it extends 
upward to the head is apt to be most marked on the forehead at the border 
of the hair. Earely does the disease develop upon the scalp without some 
characteristic lesion being present on the extremities or body. The scales are 
pearly white and dry, not fatty as in seborrhcea. Psoriasis usually occurs in 
circumscribed patches, roundish in outline, and underneath the scales the 
skin is red. Seborrhcea is often diffused, and the surface of the skin under- 
neath the scales is frequently pale in color. The location, course of the disease, 
character and color of the scales will serve to distinguish even closely similar 
lesions of psoriasis from seborrhoeic dermatitis. The two diseases often co- 
exist; the editor having seen twelve mixed cases within the last six months. 

Tinea circinata and tinea tonsurans may be determined by the micro- 
scopical discovery of the parasite. Eingworm of the scalp generally occurs 
in circular, less diffused patches than in seborrhcea, and generally some broken 
stumps of hairs can be found in the affected area. In both forms of ring- 
worm there is an absence of greasy scales common to seborrhoeic disease, and 
present a probable history of contagion. 

Impetigo contagiosa would only be mistaken for seborrhoeic crusts after 
the lesions had become dry. The former is an acute affection, occurring 
chiefly in children, in the form of discrete vesico-pustules which sometimes 
coalesce, soon rupture and dry into rather bulky honeycomb-like scales. It 
lasts rarely more than two to three weeks, unless kept active by auto-inocula- 
tion from neglect, etc. 

The papulo-squamous or the crusting stage of a pustular syphilide might 
at first sight resemble the accumulated scales of seborrhoeic spots of the scalp 
and face. The history of the case, giving other evidences of syphilitic infec- 
tion, such as the primary sore, mucous patches, other forms of syphilides, 
etc., and the puriform secretion found on removal of the crusts in the pustular 
form will establish the nature of the lesions. Unna claims that the two 
diseases often exist together, and that the seborrhoeic process may dominate 
the objective appearance. 

Lupus erythematosus in atypical form may rarely resemble an also 
atypical seborrhoeic dermatitis. Even then the differences are more numer- 
ous. The patches of the former are better defined than in the latter; the color 



78 SEBORRHEIC DERMATITIS 

is a deeper (violet) red than that seen in most forms of seborrhceic inflamma- 
tion; the scales are very adherent and dry, as compared with the easily de- 
tached and greasy sebaceous accumulations of the latter. Lupus erythema- 
tosus is due to a new growth and is often followed by scarring. Seborrhceic 
dermatitis is a functional and inflammatory disorder, and on recovery the 
texture of the skin is unchanged. 

Prognosis. — In all except the rare generalized form of seborrhcea the 
prognosis is reasonably good. Some are easily cured, others are equally 
obstinate to treatment. In seborrhceic dermatitis of the scalp, except in 
infants, it should be borne in mind that an attendant baldness may be perma- 
nent, though sometimes the piliary growth can be partially renewed. 

Treatment. — The accumulations of sebum upon the surface of the skin 
may act as a mechanical irritant; or, if decomposed, as a chemical irritant; 
therefore, such deposits should be removed by mechanical methods. Gentle 
frictions with olive oil, sweet almond oil or fresh lard will loosen the scales, 
whieh> may then be wiped away; or cleansing with any toilet soap and water 
will clear the surface, after which it should be quickly dried and very lightly 
anointed with some non-medicated oil or fat. Some cases of seborrhceic 
dermatitis undoubtedly become parasitic, and local causal treatment is indi- 
cated. In mild cases alcoholic solutions may be efficient. Green soap may be 
combined with alcohol in equal proportions, which, after filtration and scent- 
ing with some perfume, if desired, may be employed in place of ordinary soap. 
This should be sponged over the affected part, and then sufficient warm water 
used to make a free lather; finally washing off with clear water, drying, and 
anointing as before directed completes the measure. Brandy or whiskey with 
ordinary soap may sometimes be substituted for the green soap. Or, again, 
following the first method of cleansing, the following lotions may be em- 
ployed : Sulphur one drachm, alcohol and rose water of each two ounces, gtycer- 
ine half an ounce; or sulphuric ether and biborate of soda, each three drachms 
dissolved in ten ounces of distilled water. The latter lotion can be used 
without first cleansing the part, when the scales are not abundant; and it 
may be followed by the light application of a non-medicated oil, such as 
lanolin one part and sweet almond oil four parts. In persons with delicate 
or sensitive skins mildly alkaline aqueous solutions, such as ammonia, car- 
bonate of potassium, bicarbonate of soda and borax, may be used for cleansing 
purposes, followed, after washing off and drying, by some mild anti-parasitic 
ointment in place of the non-medicated oils. The following combinations, 
perfumed if desired, will be found in a variety of cases useful: calomel in the 
strength of five to twenty grains to the ounce of fresh lard, or the ammoni- 
ated mercury in the same proportions; sxdphur one-half to two drachms to 
the ounce; salicylic acid, resorcin or beta naphlhol, ten to twenty grains to 
the ounce. In seborrhceal affections of the genitals, umbilicus and axilla, 
especially in stout individuals, ointments shottld be seldom used. Here lotions 
or dusting powders are better, when any medicated or anti-parasitic applica- 
tions are needed after cleansing. Of the latter, finely powdered boric acid 



SEBORRHEIC DERMATITIS 79 

one part to four of starch or talc; powdered salicylic acid one part to ten of 
starch; and the compound stearate of zinc are among the best. All powders 
should be finely pulverized. Choice of the foregoing local measures may be 
made for individual cases of seborrhcea and seborrhceic dermatitis occurring 
on the hairy or non-hairy parts. 

The effect of these applications is almost purely mechanical or anti- 
parasitic. They act to remove a maintaining cause (the causa occasionalis of 
Hahnemann), and do not remedy an internal condition, but remove external 
obstacles to a cure. 

Rarely is stimulating (pathogenetic) local treatment required beyond that 
incident to the medicated applications already named. When needed in obsti- 
nate cases, to aid in bringing about the functional tone of the skin, resorcin 
or the tincture of pilocarpine, caniharis, capsicum, nux vomica or ergot 
incorporated in cold cream or other soft ointment, in the proportion of ten 
to thirty drops to the ounce; or, still better in many cases, in lotion of five 
to twenty drops to one drachm of boroglyceride and seven drachms of rose 
water may be employed. 

All local applications should be graduated in strength and quality to 
meet the local needs and the sensitiveness of the skin in each case. 

Stimulation applied to the spine of the patient by the regular application 
of the large, flat vacuum electrode attached to the high frequency apparatus, 
or applied directly to the seborrhceic area from the D'Arsonval apparatus with 
or without the Oudin resonator, will often obviate the need of strong local 
ointments. 

Physiological attention to the whole skin may be important. A daily 
cold bath invigorates the skin as well as the general system. Rock salt may 
be added to the water, in a proportion of a half ounce to an ounce to the 
gallon, to increase the effect of the bath. Other physiological treatment con- 
sists in the correction of habits which may have caused or aggravated the 
disease, and which were briefly named under etiology. Regulation of diet 
and exercise so as to promote healthful nutrition, and the relief of other 
disorders of the economy which may have had a causal relation to the sebor- 
rhceal disturbance are sometimes essential steps in a cure. 

Internal pathogenetic treatment is always important, and when the con- 
stitutional indications are clear, often the only treatment required. This 
I have been able to demonstrate over and over in patients coming to the 
clinic, who could not or would not carry out systematic local measures. See 
indications for Agar., Am. mur., Brij., Cal. acet., C. carl).. Chel., Colch.. 
Hydr., Kdli orom., K. mur., K. Sulph., Kresot., Merc. viv.. Mez., Nat. arsen.. 
N. mur., Nit. ac, Pet, Phos., Selen., Sepia, Sul. and Vinca. 



80 COMEDO 

COMEDO 

(Black-head; Acne punctata.) 

Definition. — A disorder of the sebaceous function in which the 
inspissated secretion plugs the ducts of the sebaceous gland. Comedones 
are seen upon the surface as small blackish points or papules, which may be 
depressed, on a level with, or slightly elevated above the surface of the skin. 
They are readily pressed out of the ducts, and, from their resemblance to 
small maggots, have been vulgarly called "skin worms." When examined 
they are found to be whitish masses of sebum, and the black extremity, which 
presented at the surface, due to dirt and cornefied epidermic cells. The 
usual location of comedo is upon the forehead, nose, chin, cheeks, neck, back 
and penis. In number they may be few and scattered, or many and near 
together. They, are unattended with any local subjective symptoms, and may 
remain for years without apparent effect on the surrounding tissues; they 
are, however, frequently associated with seborrhcea, and they may, by mechan- 
ical or other irritation, give rise to acne. They are most common, also, at 
the same period of life as the two latter diseases; that is, the puberal epoch 
of both sexes, but they may appear at any age. Thus they have been observed 
in children, on parts of the skin subject to heat and moisture; and in older 
persons subject to dyspepsia, on the "flush area" of the face. Here they are 
smaller than in the usual form and tend to become grouped together. Smaller 
comedones are also seen sometimes upon the trunk, but not grouped. 

The double or multiple comedo, usually upon the back, consists of closely 
grouped black-heads having a common glandular cavity. 

Etiology and Pathology. — Comedo usually begins at an age when the 
oil glands and hair growth are active. The disorder in the majority of cases 
is probably due to a general or reflex cause. Often there seems to be a con- 
nection between constipation of the bowels and constipation of the sebaceous 
gland; but dyspepsia, scrofula, chlorosis, menstrual disturbances and cachec- 
tic conditions are at times plainly related, as proved by the. good effects upon 
the skin of treatment of those disorders. The fact that the disorder may occur 
in seemingly vigorous young people indicates there may be a local cause. 
Those subjects who work constantly in dust or dirt and who do not use soap 
and water freely may develop comedones from the nature of their habits. 
However, the pathology is suggestive. The sebaceous glands chiefly affected 
by comedo are those which contain the lanugo hairs, whose growth is espe- 
cially active at puberty. The follicles of these rudimentary hairs, according 
to Biesiadecki, often rest at an acute or even right angle to the duct of the 
gland, and as the hair grows its point meets the wall of the duct and occa- 
sionally turns downward upon itself ; thus acting as a foreign body to produce 
irritation of the duct and increased proliferation of the epithelial elements, 
which go to form the outer covering of the comedo. Hair filaments are 
frequently found in the contents pressed out of the sebaceous duct. The 
small mite, known as the acarus folliculorum, found sometimes in the ex- 



COMEDO HI 

ternal part of the comedo, and which excites a follicular inflammation in 
dogs, has no etiological weight in the human species, since it is also found in 
healthy follicles. Unna's opinion that the dark point which marks the 
comedone is due to pigment derived from the secretions, changed, perhaps, by 
exposure to the air and light, seems the true explanation, although fine parti- 
cles of dirt are doubtless the causes in specific instances. 

Diagnosis. — Comedones are easily distinguished from all other lesions. 
Grains of gun-powder imbedded in the skin may closely resemble them. The 
history of a gun-powder accident and the impossibility of removal by pressure 
alone will serve to differentiate the latter. Occasionally cases of unusual char- 
acter or distribution are seen. In the absence of diagnostic lesions of other 
cutaneous disease, the expression from the sebaceous ducts of moulds contain- 
ing more or less greasy matter will enable one to recognize the nature of the 
disease. The association sometimes of comedo in few or large numbers with 
seborrhcea and acne needs to be kept in mind. The frequent application of 
pigments to the face, or medicated preparations of sulphur, mercury, tar, etc., 
may leave minute deposits at the orifices of the gland ducts and give an 
objective likeness to comedones. A slight examination will reveal the lack 
of any real comedo. 

Prognosis. — The disease is always curable by appropriate measures of 
treatment, and tends to spontaneous resolution after a variable period of 
delay. With great rarity the site of a comedo continuing through middle 
life may become the starting point of a warty epithelioma. 

Treatment. — Mechanical measures may be employed to give temporary 
relief from the disfigurement of comedones, especially when situated, as com- 
monly, upon the face. The affected surface of the skin should be well moist- 
ened with glycerine and water, or a more agreeable lotion may consist of 
glycerine one-half ounce, rose water two ounces, and oil of eucalyptus twelve 
drops. Then the Kippax comedo extractor can be employed to remove as 
many comedones as is thought advisable at one sitting. This little instru- 
ment, which consists of solid metal with an acne lance at one extremity and 
a curette at the other end, in which an aperture has been cut on the reverse 
side and slightly rimmed out to fit around the point of the comedo, should 
always be used by making firm pressure in place of the more convenient watch 
key or thumb nail, but which give rise to more pain and liability to bruise 
the skin. Sometimes the point of a fine needle can be used with advantage 
to loosen the epithelial rim of the comedo before making pressure with the 
extractor. After treatment consists of bathing the parts with hot water, fol- 
lowed, if needed, with an application composed of the above glycerine lotion, 
to which three times the quantity of dilute alcohol has been added. If there 
is much sense of soreness, ten drops to the ounce of arnica tincture can be 
added with benefit. These procedures for removal may need to be repeated 
occasionally, as the plugs reform. 

When, for any reason, extraction of the retained secretion is not at- 
tempted, other mechanical means will accomplish some good, such as a thor- 



82 MILIUM 

ough daily rubbing with a soft fat or oil, followed by friction with a nail 
brush, and soap and water, ending with the light application of the lotion 
last named. In obstinate cases, a thin paste made of kaolin one ounce, glycer- 
ine six drachms, and vinegar one-half ounce, may be used to loosen the seba- 
ceous plugs, or one-half drachm of precipitated sulphur in glycerine and rose 
water, half ounce of each and milk of magnesia, three ounces, may be used 
as a stimulant. Local massage by competent operators or with an electric 
vibratory or mild treatments with high frequency currents, also serve to give 
better tone to the parts affected. When possible external treatment of the 
face should be done in the evening, so its immediate effects may be the least 
apparent. Unirritated comedones on the unexposed parts of the skin need 
not be treated locally, as they are nearly certain to disappear spontaneously 
or from general treatment. 

Physiological measures of treatment suggested for seborrhcea are applica- 
ble to comedo, and, ^together with the internal pathogenetic remedies, often 
render local treatment beyond simple mechanical cleanliness unnecessary. See 
indications for Dig., Juglans reg., Nit. acid, Pet., Sabina, Selen., Sepia and 
Sulphur. 

MILIUM 

(Acne albidia; Strophulus albidus; Grutum.) 

Definition. — Pearly white, millet seed to slightly larger sized seba- 
ceous cysts, situated under the epidermis, generally located on the face 
where the skin is thin and devoid of much subcutaneous fat. 

Milia are occasionally congenital, but are most common in young adults, 
and may occur at any age. Their ordinary situations are about the eyelids, 
cheeks, temples, the external genitals of men, and the internal face of the 
labia minora of women. They are not infrequently found about scar tissue. 
They usually appear to be just within or upon the skin, but occasionally pro- 
ject from it and look as if filled with a milky fluid. They develop very slowly 
and may persist for a long time; very rarely reach a larger size — grape seed 
to a small bean — and finally, if not removed by artificial means, disappear 
with the normal desquamation of the epidermis. They are unattended with 
any subjective sensations, and are of slight clinical importance otherwise than 
the disfigurement they produce. 

Etiology and Pathology. — Whether milium is due primarily to causes 
which interfere with the expulsion of sebum or to some interference with the 
transformation of epithelium lining the gland into fat, is not determined. 
In milia occurring in the neighborhood of cicatrices, following loss of tissue 
from injury or disease, the cause is purely mechanical and results from either 
the severance of one or more acini of an oil gland from the main portion, 
or from compression by a contracting band of cicatricial tissue. In some cases 
the pathology of milium would indicate an origin from some primary defects 
in the normal transformation of the epithelia of the gland. Thus, calcareous. 



w i;\ B8 

horny and colloid changes have been found. Robinson suggests that milia 
which do not contain fat ma}' originate from misplaced embryonic cells from 
the hair follicles or mucous layer of the epidermis. Ordinarily, a milium is 
composed of a fatty nucleus and a covering of several thin envelopes of cor- 
netied epithelia. As this mass, from some part of a superficial sebaceous 
^land, approaches the surface it is covered by a thin layer of the supra-im- 
posed corium containing papillae and the transparent epidermis. After in- 
cising the external cover, a spherical shaped body can be pressed or lifted out. 
appearing of nearly the same size as when seen in situ. Rarely can the opening 
of the sebacious duct be found. 

Diagnosis. — rMilia can hardly be mistaken for any other lesion. Vesicles 
of the same color may be recognized by their fluid contents and usual acute- 
ness of development. The minute growths of xanthoma simplex, which com- 
monly are found about the inner part of the eyelids, may be distinguished 
from milia by their yellow hue, and, in case of doubt, by the inability to re- 
move them by the means generally employed to remove milia. The black- 
ish points of comedones, their situation in the sebaceous duct, and their shape 
on removal, are sufficiently unlike milia. Prognosis is invariably good. 

Treatment. — Most individuals afflicted with milia endure the slight cos- 
metic disfigurement, or in a rude way treat themselves. A milium may be 
easily removed without leaving any blemish by opening the outer covering 
with a milium or acne knife and gently pressing or turning it out. Immediate 
application for a few minutes of very hot water is the only further local treat- 
ment needed; though touching the sac-like opening with iodine tincture, 
fifty per cent, solution of chromic acid, etc., have been advised. Electrolysis 
is a satisfactory method of treatment and especially as applied to milia of the 
male external genitals. Internal medication should be directed to any peculiar 
features of the local lesions or constitutional condition if present. 

WEN 

(Steal o ma : Atheroma; Sebaceous cyst.) 

Definition. — Wens are tumor-like sebaceous cysts, larger than milia, 
sometimes reaching the size of a hen's egg. Wens are most commonly found 
upon the scalp and neck, but they may occur in any part of the skin supplied 
with sebaceous glands. They usually grow slowly, give rise to no pain or 
change of color in the external skin over them unless they become inflamed. 
There may be one or several cysts, but they are rarely numerous. They are 
usually round in shape, sometimes flattened on top, and occasionally ir- 
regular in outline; situated beneath, within or upon the skin, but seldom 
attached to the deeper tissues. Occurring on the scalp, they may be covered 
by the longer hairs or protrude to an unsightly degree ; and if baldness exists, 
lead to considerable disfigurement. The duct of the glands is generally closed, 
but may be found in some cases patent enough so that some of the contents of 



84 ACNE VULGARIS 

the cyst can be pressed out. To the touch wens impart a doughy or elastic 
quality, as they are either rather flaccid or tense. If they become inflamed 
they feel softer as a rule, and are then liable to result in suppuration and 
ulceration. 

Etiology and Pathology. — In most cases wens are caused by a reten-' 
tion of the product of the sebaceous glands and a counter thickening of the 
glandular envelope from pressure, forming the cyst wall. The contents of 
the cyst are made up from masses of more or less changed sebum and broken 
down epithelia, and as a result may vary in consistency from a granular, 
cheesy, semi-solid to a milk-like fluid; sometimes, also, they contain a rudi- 
mentary hair. Other pathological changes occur in some cases, such as a con- 
nective tissue new growth, forming a large part of the tumor; and atheroma- 
tous and calcareous degenerations. 

Diagnosis. — Fatty tumors may be distinguished from wens by the lobu- 
lated and "pillowy" sense to touch of the former, their different location, being 
situated about the shoulder blade, loins and buttocks in nearly all cases, while 
wens are seldom found other than on the scalp and neck ; from syphilitic nod- 
ules, by the evidences of other lesions or history of syphilis, and their usual 
pain and tenderness to pressure. 

Broken-down wens may be differentiated from boils and circumscribed 
abscesses by the history of long-standing tumor, previous to suppuration. 

Treatment. — Operative treatment only is indicated. Excision under 
strict antiseptic precautions is probably the best. The parts over the cyst 
having been incised, the cyst wall is carefully dissected out with or without 
rupture and evacuation of its contents. The wound may be evenly closed 
without sutures, dusted over with iodoform, thickly covered with antiseptic 
gauze, and held in place by a bandage. Unless some disturbance arises this 
dressing need not be removed for several days or a week. The author has 
never seen other than good results from this method. Owing to the danger 
from wound infection on the scalp other methods of treatment have been 
advised. Of these, caustics are usually too painful to be generally employed, 
and the ether injection method or the application of fuming sulphuric acid 
have no decided advantage. Small wens may be incised, their contents ex- 
pressed and the electric needle (electrolysis) applied at several points of the 
cavity. 

ACNE VULGARIS 

Definition. — An inflammation of the sebaceous glands and of the 
follicles of the lanugo hairs situated therein. Acne is one of the most com- 
mon and intractable of skin diseases. It is usually a folliculitis, less frequently 
a perifolliculitis, and probably is a direct result in some cases of decomposi- 
tion of the retained sebum. The characteristic features of acne are: (1) Loca- 
tion on. the face, neck, shoulders and chest, rarely appearing to any extent on 
any other part of the cutaneous surface. (2.) Period of occurrence coincident 




Fig. 31— ACNE VULGARIS 



Patient is a young man of twenty-three. Comedones, papules and pustules are 
scattered about the face and numerous scars bear evidence of deep seated pustula- 
tion. Duration, five years. He complains of soreness and pain in and about the 
lesions when pressed. Cured under the use of he par sulphur third decimal for over 
a year and arsenicum brom. sixth decimal'^ for two months. 



ACNE VULGARIS 



85 



with the development of sexual life of both sexes. (3.) Its perpetuation, if 
not origin, from some irritation (physiological or pathological) of other near 
or remote organs or tissues. (4.) Primary lesions of small, red, solid eleva- 
tions of the skin, followed by spontaneous resolution, or by central pustulation, 
without subsequent scar if superficial, with pitting if deep seated or involv- 
ing the true skin and successively appearing singly or in groups of a few or 
many. Simple acne, which is chiefly a blemish of youth, untreated, is a self- 
limited disease of from five to eight years' duration. Acne occurring in mid- 
dle life is of uncertain duration, and usually of a more pronounced inflam- 
matory type, attended with the formation of tubercles, and in many cases with 
marked induration of adjacent tissue. In such cases, if the lesions are per- 
mitted to mature (suppurate) scarring follows. 

Pathologically acne may be divided into acne papulosa and acne pustulosa, 
but as the smaller lesions occur chiefly in youth and the larger in middle life 
a better division seems to be into acne simplex and acne indurata. All skin 
diseases, with secondary acnoid eruptions, or clinically different, should be 
excluded, or qualified by other titles, such as bromine acne, acne varioli- 
formis, etc. 

Acne simplex. — The location of acne simplex is most often on the fore- 
head, cheeks and chin, but it is quite common on the back of the shoulders 
and upper part of the chest, and sometimes occurs on the extremities. The 
eruption is usually bilateral without symmetry. While nearly always develop- 
ing about the age of puberty in both sexes, it may occur at an earlier or 
later period of life. The lesions consist of comedones, papules and pustules, 
and vary in size from a pin's head to a split pea; they vary in number from 
one or two to hundreds. Frequently a comedo forms the centre of the 
papule and can be seen also after the transition into a pustule. Papules often 
appear independent of the comedones; and in some cases many papules re- 
solve without passing into pustules. Usually the lesions may be found in all 
stages of evolution in the same individual — from the blackish pointed comedo, 
the bright to dusky red papule, to the yellowish white pustule with 
a more or less red areola. The effects of previous lesions — stains and 
scars, may be found also. The former disappear gradually and the superficial 
scars become much less distinct in time. A negative feature of acne is the 
absence of subjective sensations, except a sore feeling when pressed upon and 
sometimes a slight burning. Acne simplex is essentially a chronic disease, and 
untreated it may last from the advent of puberty to the period of full maturity, 
when it is likely to spontaneously disappear. Occasionally it passes gradually 
into the deeper seated acne indurata and in a small proportion of cases the 
two forms co-exist in youth. 

Acne indurata. — Acne indurata occurs in the same localities as acne 
simplex, but is more frequently found upon the neck and back than the latter. 
It pursues a still more chronic course, rarely or never entirely disappearing 
without treatment. The lesions may be few or many, isolated or close together. 
They originate as deep seated round, ovoid or flatfish indurations; vary in size 



8G ACNE VULGARIS 

from a pea to a cherry, and a s they slowly enlarge, the skin becomes a dark 
reddish color. Some suppurate quickly, more are indolent and contain little 
pus, which, if let out by incision, is apt to form again. If not opened there 
is no tendency to spontaneous rupture, and resolution may be dela} r ed for 
weeks. Comedones are not usually present, and when found have no direct 
pathological relation as in acne simplex. Scars are a frequent effect of acne 
indurata, at first of a purplish color they remain stationary, or very slowly 
fade away. Keloidal transformations sometimes follow, and rarely the acne 
induration may pass on to fibroid degeneration without the occurrence of sup- 
puration. 

Seborrhcea and seborrhceic dermatitis ma}' complicate either form and 
give rise to symptoms common to those affections. The term acne has been 
used freely in giving title to cutaneous diseases little or not at all related to 
true acne. A few need be named here in explanation only : 

'I. Acne cachecticorum lesions are pea to cherry sized, flattened, flaccid, 
vivid red formations, containing a little sero-purulent fluid; located chief! y 
upon the trunk and extremities and occurring in persons poorly nourished, 
depressed, strumous, or scorbutic, and is frequently associated with lichen 
scrofulosum. Though it may resemble acne indurata of a low type, it is prob- 
ably partly or wholly tubercular in nature (see scrofuloderma). 

B. Acne artiftcialis, drug eruptions (see dermatitis medicamentosa). 
' C. Acne rosacea and acne hypertrophica (see rosacea). 

D. Acne d'ecalvanS (see folliculitis decalvans). 

E: Acne keloid' (see dermatitis papillaris capillitii ). 

F. Acne moUvscum (see molluscum contagiosum) . 

G. Acne adenoid (miliary lupus, etc.) (see lupus vulgaris). 
Etiology. — The causes of acne are varied if not numerous. It has been 

viewed as a local disease, and when due to local stimulants or irritants, as the 
tar preparations, for instance, this is true. Here it is an artificial disease, how- 
ever, and quite different in origin from the true disease arising from a vital 
source more or less remote from the skin. A predisposing cause is no doubt 
the greatly increased activity of the sebaceous glands in the few years subse- 
quent to the advent of puberty. From the hypersemia of physiological activity 
it is only a step to congestion, if some influence intervenes to prevent the 
normal intermission in physiological hyperemia of a part. The flushing 
of the face from moderate mental emotions is a common illustration of a 
reflex effect on the skin. Gastro-intestinal reflexes are known to affect the cir- 
culation of blood in the face. Flatulent dyspepsia and constipation are often 
apparent factors. Abnormalities of menstruation appear to be the underly- 
ing cause in nearly fifty per cent of cases in girls and young women. Genito- 
urinary disturbances, masturbation, and affections of the mucous membrane 
of the nose and throat may be occasional causes. In many cases the pre- 
disposing influence is probably a general one. Anaemia and debility of various 
kinds in the young, too rapid growth, a weakened circulation, as manifested 
by cold extremities; the scrofulous type of constitution, etc.. may be men- 



ACNE VULGARIS *7 

tioncd. Such causes operate to lower nutrition, which precedes the local im- 
pairment of function in the sebaceous glands. 

In middle life sedentary living, the gouty diathesis, diabetes and struma, 
together with functional disturbances in the digestive, urinary and upper res- 
piratory tracts, uterine and ovarian diseases in women and intemperance 
of one kind or another in both sexes arc the most frequent causes of acne. 
In a lew cases the causes seem to be entirely local. Whether the invasion of 
the sebaceous follicles by the staphylococcus pyogenes is an immediate cause, 
or a degree of inflammation from changed sebum first arises is not deter- 
mined. The surface of the skin is nearly always subject to the presence of 
pus cocci, and the possibility of their being local exciters and disseminators 
of acne under favoring systemic or surface conditions may be a reasonable 
basis for some of the modern local treatment of this disease. 

Pathology. — The pathological changes in acne result from inflamma- 
tion, frequently carried to suppuration and destruction in some degree of the 
sebeceous follicle. According to Elliot, the inflammation begins in the tissue 
around the folicle, or as a perifolliculitis and only subsequently is the follicle 
invaded. Under lowered vitality or changed nutrition ordinary causes may 
excite the inflammation. Thus temporary or reflex hyperemia, the elimina- 
tion of some virus poison or effete material by the glands, retained secretion, mi- 
cro-organisms, etc., may be the link between primary etiology and pathology. 
One or more follicles may be involved and may be partly or wholly destroyed. 
Pus-filled pockets ma}' also form in the adjacent tissues, ultimately discharg- 
ing into the gland cavity. In the contents of the gland numerous micrococci 
can be found, and recently Unna and Gilchrist have found a special bacillus 
in the acne pustule. Though this microbe has definite pus producing prop- 
erties, its shape has been variously described as thick, rod-like, straight or 
curved. 

Diagnosis. — Bearing in mind the characteristics of acne, mentioned at 
the beginning of the chapter, its usual association with comedones (in acne 
simplex) and frequency of occurrence, little difficulty will be found in diag- 
nosis. It might be confounded with papulo-pustular eczema, rosacea, the 
pustular syphilide, small-pox and sj^cosis. 

Papulo-pustular eczema may be known by its smaller lesions, occurring in 
patches, unconnected with comedones and showing signs of exudation and 
crusting. Itching is also a prominent symptom of eczema. Rosacea occurs 
usually in mature life; begins with temporary, followed by more permanent 
redness of the skin of the face, and dilatation of the superficial blood-vessels. 
Acne lesions, if present, are secondary in occurrence. The pustular syphilide 
appears generally in groups, and underneath the crusts which cover the base 
of the lesion small excavated ideers may be found. A history of the case 
and the presence of other forms of syphilide, with a wider distribution than 
is common to acne, may further aid the diagnosis. The tubercular or gumma- 
tous syphilide of the skin is apt to occur in groups, and degenerate into ulcers, 
which often spread by one-sided extension. When the nose only is affected. 



88 ACNE VULGARIS 

the resemblance to acne may be very close, and other evidence of syphilis, 
or the effects of treatment, may need to be known in order to determine its 
nature. Small-pox can be excluded by the absence of constitutional symptoms, 
or the duration of the eruption longer than that eruptive fever. Sycosis oc- 
curs only in adult males, is strictly limited to the bearded part of the face, 
and a hair occupies the centre of the lesion instead of a comedo, as in acne. 

Prognosis. — Acne is a curable disease under proper management and 
treatment. In making any forecast of the probable duration of acne, allow- 
ance must be made for the uncertainty of the patient following the directions 
of a protracted therapeutic course especially if the causal treatment involves 
continued self-denial. 

Treatment. — In the treatment of all diseases it is of the first importance 
to remove the learnable cause or causes, original or secondary. In acne it is 
almost the sine qua non to success. Moral perversions are to be met by 
moral remedies; the pride evoked in some, in others fear aroused by exag- 
gerated pictures of evils yet to come in disfigurement of skin and in other 
directions. In the correction of onanism there is no auxiliary treatment equal 
to physical weariness or exhaustion, and in acne from this cause abundant 
exercise is an efficient aid. Sources of irritation in the genito-urinary sphere 
should be sought for when suspected. A contracted prepuce or meatus, ad- 
hesions in both sexes, and uncleanliness in the sometimes otherwise cleanly 
are conditions to be corrected. Cool or cold water should always be used to 
bathe these parts, and, as a rule, for the daily bath. Frequent or long con- 
tinued disturbance of function in any part of the digestive tract is often the 
hidden fire which flames forth in acne and its related disease, rosacea. The 
art of dietetics pertains here. In the plethoric, reduction and more or less 
substitution of vegetable for animal food is usually indicated. In the anaemic 
increase of quality or quantity of nitrogenous food, frequently of the animal 
kind is needed. Idiosyncrasy sometimes plays a part. So simple a food as 
boiled rice may cause congestion of the face, and it is not uncommon for such 
effects to follow the use of fruit jellies, beef, shell fish, etc. In nearly all 
cases too little liquid is taken. The skin is an important organ of excretion 
as well as secretion, and few realize the necessity of a full supply of water to 
maintain these functions in healthful activity. Attention to regimen and 
habits of exercise will often cure the very usual constipation. An indicated 
drug may, however, be needed for this lack of function. 

Massage, mechanical or otherwise, general or local, and the general tonic 
use of static electricity and of the high frequency currents have proven of great 
value in improving the general tone. 

Local treatment, if employed, should be on well defined principles. In 
acne these may all be embraced under (1) absolute cleanliness; (2) patho- 
genetic irritation or inflammation; (3) depletion, and (4) radio- and photo- 
therapy and the high frequency currents. The first may be obtained by the 
use of soap and water, or a medicated soap having solvent properties, such as 
salicylic acid or ichthyol, and the occasional use of a saturated solution of 






ACNE VULGARIS 89 



boric acid applied hot, or the same in strong alcohol applied cold. Some- 
times cleanliness and artificial irritation may be had from the same agent, 
as in the use of soft soap or green soap applied with friction. The use 
of very hot water alone dissolves and washes away the secretions to some 
extent, and at the same time produces a temporary congestion which is more 
or less curative in its reaction. This simple measure may be pushed too far, 
however, and defeat rather than aid a cure. As a rule, local applications to 
the face should be made at night shortly before retiring, giving time in the 
interval before morning for the temporary aggravation, if any, to subside. 
When the skin is sensitive, a mildly antiseptic ointment may follow the bath- 
ing, to be washed off in the morning. Boric acid, twenty to forty grains to 
an ounce of cold cream, or salicylic acid or resorcin, five to twenty grains to 
an ounce of the same vehicle, may be employed. If needed, a dusting powder 
composed of boric acid, one part to eight parts of finely powdered starch, or 
stearate of zinc can be used. Calendula, bismuth, calomel, ichthyol or aristol 
can be applied likewise. 

More decided pathogenetic effects (stimulation, etc.) may be needed in 
cases of acne of a severe type, or occurring in persons who have thick and 
sluggish skins, and remedies of an antiseptic character are usually chosen. 

A simple formula for this, purpose is : 

1$. Hydrarg. bichlorid srr. 8. 

Spr. vini rect 5 2. 

Aquae distil : o A. M. 

Whenever the above or similar prescription is prescribed for local use, 
the patient should be told that it may excite irritation, and then it should 
be discontinued temporarily for milder measures. When employed, cleansing 
treatment should precede its application and a mild ointment (before named) 
follow, if needed. 

Ichthyol soap and lotion will be found serviceable in some cases of acne 
for cleansing and stimulating purposes. Stiefel's (10%) ichthyol soap may 
be first used to thoroughly cleanse the surface, twice daily, followed im- 
mediately by the following lotion, recommended by Unna: 

1$. Ammonia- sulph. ichthyolat gr. 12-120. 

Alroholis (90%), 

Etheris aa 3 4. M. 

The strength of the ichthyol may bear a relation to the degree of the 
disease or the texture of the skin. It is advisable to always begin with a 
mild strength and increase it subsequently as required. 

Numerous applications containing sulphur have been recommended for acne 
pustulosa, and among these the following has given the most satisfaction : 

R. Sulphuris precipitati 5 t. 

Glycerin i, 

Aquae rosea aa 5 J. 

Milk of magnesia q.s. 5 4. M. 



90 ACNE VULGARIS 

Acne of the trunk calls for more energetic treatment and stronger lotions 
or ointments. A thirty per cent, solution of formaldehyde has proven satis- 
factory for acne of the back. 

Depletion is effected by the use of the acne lance. This is inserted in the 
centre of the papule or pustule, to give free exit to retained sebum or pus, 
which may be gently pressed out with the comedo extractor or with the dermal 
curette. Afterwards hot water can be applied to the parts for a few minutes 
to further depletion and discharge. The lancing is only slightly painful and 
may be repeated every few days. The cases in which depletion is indicated 
are those which do not yield to other well-directed treatment, and when 
the lesions are large or deep seated. Puncture in selected cases hastens cure 
by relieving the follicles of retained matter, the capillaries of stagnant blood, 
by limiting the formation of pus, and by preventing rupture of the epidermis. 
In the deeply situated suppurating lesions it is an essential procedure to pre- 
vemSscarring. After puncture of acne lesions the surface should be cleansed 
with alcohol or some alcoholic preparation. 

For many cases of mild acne (without pustulation) the regular applica- 
tion of the high frequency currents has proven most beneficial in the editor's 
hands. Nearly one hundred cases have received this method of stimulation, 
once or twice a week, for about five minutes. The particular form of high 
frequency currents used should depend on the exact nature of the case, the 
resonant (Oudin) and the hyperstatic (Piffard) being suitable when exces- 
sive stimulation is needed, while the helicoidal shunt of D'Arsonval suffices 
ior the large majority of mild cases. 

The Rontgen rays have been of marked benefit in the chronic, obstinate 
indurated and deep seated acne, especially when the pus infection is para- 
mount. The editor makes his exposures at a distance of eight to twelve 
inches, and for four to ten minutes' duration. This is repeated every three 
to five days, and it has seldom been necessary to go beyond ten treatments to 
secure permanent results. The Friedlander hood is used to cover the tube, and 
parts not to be treated are also protected. It is seldom necessary to carry the 
treatment beyond a point Avhere a mild erythema develops. 

In no disease is there better opportunity to watch and estimate the 
therapeutic effects and value of drugs and the relation of internal subjective 
phenomena and objective lesion thereto than in the treatment of this cuta- 
neous disease. A clearly indicated drug often benefits promptly and progres- 
sively. Not a few cases of acne, however, are unattended with subjective 
symptoms; either the causes were never apparent, or. having ceased to mani- 
fest symptoms, the momentum of the disease perpetuates itself, possibly from 
the presence of local conditions. In such cases drugs which produce papulo- 
pustular lesions, especially in the regions affected, are to be considered. See 
indications for Agar.. Alum.. Aloes. Am. <arb.. Ant. crud.. A. tart.. Arg. nit.. 
Arnica. Aurum mnr.. Ars.. A. brom.. A. iod.. Barilla act.. B. carl.. Bero., 
Bell., Borax. Bov.. Cal. pi, or.. C. sulph., Ghel., Cold,.. CrotaZ., Cor.. Cycla.. 



ACNE VARIOLIFORMIS ! " 

Dig., Graph., Hepar, Jugl. reg., Kali brom., K. bich., K. iod., A . mur., Lyco., 
Nit. acid. Nux. mosck., A. rout.. I'd.. Phos. acid, Puis., Bhodod., Sabina, 
Sarsap., Si- pin. Silica, Sul., Thuja and Zinc. 

ACNE VARIOLIFORMIS 

(Acne atrophica; Acne ulcerosa; Acne filaris; Acne frontalis sue necrotica; 
Acne rodens; Lupoid acne-, etc.) 

Definition. — A papulo-pustular eruption, occurring over the brow, 
scalp or rarely other regions, slow in its evolution, chronic in course, at- 
tended with loss of tissue, which leaves a depressed scar similar to that 
-caused by a variola pustule. 

Symptoms. — The lesion of acne varioliformis begins as a reddish -brown, 
deep-seated, pea to bean sized, indolent papule. The central portion may bo- 
come pustular, or covered with an adherent, flatfish, yellowish-brown crust 
which sometimes appears depressed below the surface. Underneath the crust 
will be found a sharply defined ulcer with an uneven color. Left to itself 
the crust may increase in size, and after an uncertain interval fall off, leaving 
a, reddish-brown cicatriform lesion, which finally becomes white. There may 
be subjective sensations of slight itching, or none at all. 

Occasionally the disease is located about the nose, ears, the back and 
sternal aspects of the trunk, and with exceptional rarity may be generally dis- 
tributed. The. lesions may be few or many;- discrete, crowded together in 
groups; sometimes linear or circinate in arrangement. The lesions are fre- 
quently pierced by a hairy filament. The course of the disease is very chronic, 
sometimes lasting for years. 

Etiology and Pathology. — No definite cause for the disease is known. 
It has been attributed to syphilis, but the relation is not frequent enough to 
warrant classing it as a syphilodermata. It is commonly a disease of middle 
life. The lymphatic temperament, rheumatic diathesis, parasites, gastroin- 
testinal irritations, general tuberculosis, and exposure to heat have been 
mentioned as causes. 

Pathologically, the eruption appears to be due to microbic infection. 
Sabouraud believes that both the microbacillus of seborrhcea and the staphy- 
lococci play a causal part. At all events, the process is inflammatory, involving 
the pilosebaceous structures, with consequent destruction of the follicle and 
surrounding corium. 

Diagnosis. — The diagnostic points of acne varioliformis are the papulo- 
pustular lesions, their slow evolution, chronic' course, resulting scars, usual 
location on the brow and scalp and appearing in middle life. Variola can be 
•excluded by the absence of constitutional symptoms and lack of rapid efflores- 
cence. Acne vulgaris may be easily distinguished by the absence of lesions 
•on the scalp, absence of vdceration and the presence of comedones, etc. A 
pustular syphilide may present objectively a close resemblance to acne 
varioliforms. With the former there mav be usuallv found other evidences of 



92 HYPERTRICHOSIS 

syphilis, such as other forms of syphiloderm, adenitis, mucous patches, and 
possibly a clear history of infection. A pustular form of folliculitis decal- 
vans may be differentiated from acne varioliformis by the small pin-head 
sized postules, each pierced by a hair, occurring in the former; its limitation 
to the hairy surfaces of the scalp, beard, etc., and the irregular patches of 
alopecia resulting therefrom. 

Prognosis. — Aside from the cicatricial deformity, a cure may be expected 
in all mild cases of acne varioliformis. Even the severe cases, while persistent, 
finally yield to treatment; sometimes the tendency to recur is a feature. 

Treatment. — Causal methods of treatment are to be instituted when any 
such basis for a prescription is found. A history of syphilis or tuberculosis 
may point to remedies. Loss of vigor, improper diet, or injurious habits may 
call for the employment of physiological methods. The Rbntgen rays have 
proven beneficial in this condition. 

Locally, perfect cleanliness will be usually sufficient in that direction. 
This can be secured by the use of soap and water alone, or in conjunction with 
some mild antiseptic lotion. Much the same preparations as advised in acne 
vulgaris have been recommended as external applications in acne variolifor- 
mis. In the few cases seen by the author, ordinary soap and water locally, 
and the administration of the indicated drug, have proved efficient. See 
indications for Arsen. iod., Colch., Kali brom. and Silica. 

C. DISEASES OF THE HAIR AND HAIR FOLLICLES 
HYPERTRICHOSIS 

(Hypertrophy of the hair; Superfluous hair; Trichauxis; Polytrichia; Hir- 

suites, etc.) 

This is a condition in which there is an abnormal growth of the hair, 
or a growth of strong hair at an age when or in situations where only- 
downy hair is normally found. This departure from the usual develop- 
ment of the hair may be congenital or acquired, general or partial, and some- 
times nearly universal. Even though the whole surface of the trunk and 
extremities are covered with hair, certain places like the ends of the fingers, 
palms, soles, eyelids, etc., are always free. The excessive growth may be in 
the size of the hair, or its length, as well as in unusual location; sometimes 
several hairs grow from one follicle. In these cases there is very often a de- 
ficiency in the growth of the teeth, seldom excess of development. The most im- 
portant forms of superfluous hair growth are those occurring upon the face 
of women, chiefly at puberty and the climacteric periods. 

Etiology. — Most cases are due to hereditary causes, such as atavism, 
mental impressions, nervous influence. Sometimes local influences, such as 
exposure to sun and wind, continued application of heat and moisture, use of 
pilocarpine, appear to have stimulated a growth of hair. Occurring in women, 
the causes are nearly always hereditary; it will be found that the mother or 



HYPERTRICHOSIS 98 

some other relatives of the same sex of the preceding generation had been 
similarly affected. Even in later life, there is nearly always some heredi- 
tary influence apparent. The disease is very much more common in 
some nationalities than in others. These growths of hair are most apt to 
occur at the climacteric period in the lives of women, and at the same time 
there may occasionally appear decided change of voice and manner. Tempo- 
rary growths of hair have been observed in pregnancy, from delayed or sus- 
pended menstruation and from injuries. Many cases of excessive growth of hair 
in normal situations have followed severe sickness, and in some the hypernutri- 
tion in this direction has seemed to be at the expense of the general system. 

Treatment. — General or extensive hypertrichosis is to be endured as 
a permanent blemish, because the difficulties of removal in time and patience 
are nearly insurmountable. At the same time health or life is not at stake, 
and the surface disfigurement can be quite or nearly hidden from view by the 
clothing. Very moderate growth of superfluous hair on the face or other parts 
may be removed by electrolysis. The success of this method, however, depends 
upon the expertness of the operator in the use of suitable instruments. Un- 
skilful attempts at extraction of hairs by electrolysis will do no good, and 
may do harm. The author has seen several cases where increased growth of 
hair has followed such treatment. 

For the operation, a galvanic battery of sixteen to thirty cells, a needle- 
holder, a fine steel or irido-platinum needle, the usual cords, an electrode, a 
rheostat, a milliamperemeter and epilation forceps, are required. A low power 
lens may be used to see the parts clearer, and may be attached to the needle- 
holder (Piffard's). An interrupter attached to the holder should not be used 
because the current should be broken at the positive electrode and not at the 
needle. The strength of the current will vary with the sensitiveness and thick- 
ness of the skin. Usually one-half to three milliamperes will suffice. 

Everything being in order, the patient should be placed in a position of 
the greatest ease for both patient and operator and in a good light. The 
hairs to be removed at the sitting may be cut off to within about one-fourth 
inch from the surface. The stub of hair left is then grasped with the forceps 
and gently pulled outward in a line with its natural growth ; at the same time 
the needle attached by means of the needle-holder to the negative pole of 
the batterjr is passed down beside the hair and on a line with it into the bot- 
tom of the follicle. Little or no force is used in inserting the needle; if 
rightly directed it slips easily into the depth of one to three-sixteenths of 
an inch, according to the depth of the follicle. The patient who has held the 
handle of the sponge electrode connected with the positive pole in one hand 
may now connect the electric circuit by placing the palm of the other hand 
upon the sponge. Evidence of electrolytic action will show immediately by 
the appearance of bubbles of froth, and in a few seconds to a minute the hair 
will come away with very slight traction with the forceps. The current is 
broken by the patient removing the hand from the sponge before the needle 
is withdrawn. 



94 HYPERTRICHOSIS 

A small papule or wheal appears at once at the site of removal; it soon 
begins to fade away, and on the second day only a point remains, which may 
be gradually transformed into a minute scar. Occasionally the scars are 
larger and more noticeable, or keloid may result from too strong or too long 
use of the electric current. Hairs near together should be removed, as a rule,, 
at the same sitting, but not too many at the same time, to avoid exhausting 
the courage of the patient, and the liability of producing undue local reaction. 
Fifteen to forty hairs represent about the limit of removal at one seance. Lan- 
ugo hairs are best left untouched unless at a later period they show a tendency 
to develop into larger hairs. 

The pain from the operation is considerable to sensitive patients, but can- 
not be called unbearable, and is almost certain to be felt less at successive 
sittings. When there is unusual sensitiveness, a ten to twenty per cent, 
solution of cocaine in alcohol may be brushed over the part. More perfect 
anaesthesia can be made by kataphoresis. This is done by moistening some 
porous material laid upon the skin with a solution of cocaine, covering it with 
an electrode and allowing a mild current to pass through. Another device is 
to dip the needle in oleate of cocaine each time it is inserted. The disadvan- 
tage of cocaine is an increased inflammatory reaction from its use, and a 
possible general effect if much is used. Bathing with warm water is the only 
after treatment needed, or if there is much soreness, arnica one part to ten each 
of alcohol and water may be used. 

Other methods of removing superfluous hair are epilation, and the appli- 
cation of depilatories. Epilation is not only painful hut worse than useless. 
as in place of the hairs extracted there are likely to grow larger and longer hairs. 
Repeated use of depilatories seldom permanently arrests the growth of hair. 
and they are always liable to inflame the skin if employed strong enough to 
separate the hair from the latter. Hence they are not recommended. If de- 
manded, the following may be effective : 

R. Yellow sulphate of arsenic, 

Quick-lime aa 5 -• M. 

Enough of the powder to make a paste to cover the hairy surface can be 
mixed with hot water and spread upon the skin with a spatula. When dry. 
or as soon as a sense of burning is felt, usually in about two minutes, it can be 
scraped off with the same appliance. 
Also: 

R. Sulphide of barium, 

Pulv. oxide of zinc aa § 1. M. 

This is prepared and used in the same manner as the first formula. 

If a depilatory is employed, it can be repeated as needed: when irritation of 
the skin results, some simple ointment can be applied, and the reddened 
skin hidden by dusting it over with a toilet powder. In cases of hypertrichosis, 
where it is impracticable for any reason to use electrolysis or depilatories, 
shaving can be indulged in; or if the hairs are few, they can be cut close to 
the skin with a pair of curved scissors every day or two. 



TRICHIASIS— FRAGILITAS CRINIUM 9b 

When it has been impossible to use other methods, especially in patients 
having a dark growth, the editor has achieved good results from the use of the 
peroxide of hydrogen applied daily on a compress, gradually increasing from 
a fifty per cent, solution to full strength. It certainly bleaches and may re- 
tard the pilary growth. 

The Rontgen rays have been used, but the results are not satisfactory, be- 
cause of the large number of treatments necessary to prevent a recurrence and 
the liability of irritation. Ten minutes is about the maximum time and 
eight inches about the minimum distance used at an exposure. 

Radium has been used in two cases by the editor, but after treatments last- 
ing an hour and repeated ten times the hairs returned at the end of a month's 
time. Its action does not seem superior to the X-rays in any respect. 

Prognosis. — The function of the hair follicle to produce hair can cer- 
tainly be destroyed by electrolysis, but failure to reach the papilla from mis- 
direction of the needle, some anatomical peculiarity, or lack of sufficient cur- 
rent, may make it necessary to repeat the operation upon individual hairs. 
Then there is always the possibility of the downy hairs taking on a more vigor- 
ous growth, especially in younger women. The prospects of success from elec- 
trolysis may be said in a general way to be in proportion to the fewness of 
the hairs and the age of the patient. 



TRICHIASIS 

This disease really belongs in the department of ophthalmology, usually 
coming under the observation of oculists. It consists in the congenital or 
acquired displacement of the hairs of the eyelids, so that they are directed 
backwards and rub the eyeball. Subsequently lanugo hairs may grow from 
every part of the tarsal margin and point in the same directions. It may affect 
the lower or upper lid of one or both eyes. The disease is generally acquired 
from chronic inflammation of a granular or purulent character. 

Distichiasis differs from the form described, in having a double row of 
cilia, the inner of which are directed inwards. Very often these hairs are not 
seen until the lids are everted. No downy hairs are seen in distichiasis. It 
may affect the whole or only a part of the lid. The effect is to produce irrita- 
tion and diseases of the conjunctiva and of the cornea. 

The diagnosis of both conditions is easily made by inspection. 

Treatment is removal either by operation or by electrolysis, and some- 
times by the administration of borax internally. 



FRAGILITAS CRINIUM 

{Splitting of the hair; Trichoxerosis, etc.) 

Definition. — This is an affection of the hair, in which the body or the 
end of the hair becomes split. 



96 TRICHORRHEXIS NODOSA 

It is usually a disease of the hair of the head, but may affect the hair 
of any part of the body. Etiologically there are two forms, the symptomatic and 
the idiopathic. Thus it may occur as a symptom of other diseases of the scalp, 
such as f avus, seborrhcea and eczema ; while in many cases there is no apparent 
cause, in some there may be debility, or general cachexia from constitu- 
tional disease. Most often the free end of the hair is the part affected ; then the 
hair is apt to curl up on itself. Sometimes only a few hairs, and at other 
times many, are attacked by the disease. "When air enters between the fila- 
ments, it gives the broken ends of the hairs a grayish look, sometimes a dusty 
look. Very often there is also a swelling of the hair, known as trichor- 
rhexis nodosa. 

Etiology and Pathology. — The cause of this disease is often due to the 
presence of parasites. In other cases there is some interference with nutrition, 
either directly of the hair, or of a general character. Pathologically the only 
abnormal changes in the hair are fissures and an irregularity in the shape of the 
shaft ; the hair bulb or root may be normal or shrunken and show evidence of 
the beginning of the disease in that part of the hair. 

Treatment. — Measures to correct any depraved conditions of health should 
be instituted by physiological or other methods. If the disease is limited to 
the ends of the hairs, they should be cut off above the diseased part. If the 
body of the hair is involved near the scalp, shaving is advisable. For internal 
use see indications for Calcarea phos. and Fluoric acid. 

TRICHORRHEXIS NODOSA 

(Swelling and bursting of the hair; Tinea nodosa; Trichoptilosis, etc.) 

Definition. — This term is applied to a peculiar disease of the hair, in 
which nodes appear along the shaft, and a sort of green stick fracture of 
the hair takes place through them. The disease develops without any pre- 
vious symptoms. The hair feels knotty to the touch, and along the shafts 
there is found a blackish or whitish transparent swelling, looking somewhat 
like the nits of pediculi. The nodes vary in size with the shape of the 
hair; commonly they are located nearer the proximal ends of the hair. 
When fracture occurs it may be transverse or longitudinal. If longitudinal and 
incomplete, then the appearance will be like that presented by pushing two 
brushes together end to end; if transverse and complete, the ends look brush- 
like, and sometimes there will be a frayed appearance, often throughout the 
length of the hair. Occurring in the beard, it often presents a singed appear- 
ance. The hair is usually firmly fixed in the follicles. The disease most often 
affects the beard of men and the labia majora of women. 

Etiology and Pathology. — The real causes of the disease are unknown ; 
they are probably parasitic, but some cases would lead us to call it a trophic 
neurosis. There seems to be at times a hereditarj'- tendency to the disease, 
and it has been traced back to great-grandparents. In the hereditary cases the 
disease is apt to show itself soon after birth. When it occurs in the beard, 



MONILETHRIX 97 

it may be partly due to frequent pulling or violent nibbing. Micro-organisms 
have been found in connection with the disease by Raymond, Bodara and 
others, while as many other authorities fail to discover any. Cases presenting 
a history of direct contagion are rare. Pathologically, the disease seems to 
begin by an increase in size of the shaft of the hair. This swelling involves 
the medulla and body of the hair, leaving the surface cuticle unaffected. As 
soon as fracture occurs degeneration begins in the inner part of the hair, and 
the medulla is absorbed. The hair roots may be unchanged or slightly 
shrunken. 

Diagnosis. — Trichorrhexis nodosa should be distinguished from piedra 
and trichomycosis nodosa, in not being clearly parasitic and in presenting 
multiform swellings or fractures of the hair shaft, with healthy spaces between. 
From piedra it may be distinguished by the absence of hard, strong, white 
masses, composed of fungi, around the hair shaft. From the extremely rare 
disease, trichomycosis nodosa, it may be known by affecting principally the 
beard, and involving the whole contour of the hair, and not placed to one 
side of it as in the latter affection; and also by the absence of a parasitic 
growth on microscopic inspection. 

Treatment. — A similar line of treatment as in fragilitas crinium is 
indicated, i.e., to improve the general and local nutrition. Shaving is the 
only effectual local method, and should be followed by the application of 
a mild antiparasitic lotion or ointment. The Rontgen rays, applied continu- 
ously twice a week for three months, cured one case of the editor's. 



MONILETHRIX 

(Moniliform or beaded hairs; Pili annulati.) 

Monilethrix is a rare form of fragility of the hair, exhibiting along 
the shaft nodes between which are narrower portions of the shaft, lighter 
in color than the pigmented nodes. A checkered appearance of the hair 
results. Fractures occur in the internodular portions, due to atrophic changes 
in these parts, whereas in trichorrhexis nodosa the seat of fractures are the 
nodes. A condition of keratosis pilaris and a varying degree of alopecia are 
usually present. 

Etiology and Pathology. — The disease occurs in both sexes, may be 
■congenital or acquired and may be present in several members of the same 
family. Kaposi and others believe that the disease is due to a periodic aplasia 
of the hair. Nervous shock has certainly been an important factor in some 
cases, and Hyde reports acquired types due to traumatisms. Probably most 
cases are congenital. 

Treatment must be directed along general hygienic and dietetic lines. 
Stimulation, local and general, may be achieved by massage, exercise and sys- 
tematic bathing. The tissue remedies should be studied. The prognosis is 
necessarily poor. 



98 LEPOTHRIX— TINEA NODOSA— PIEDRA 



LEPOTHRIX 

A rare condition in which the hair becomes dry, brittle, rough, nodular 
and loosened in the follicle, involving the pilary growth of the axillae and 
genital regions. It was first described by Paxton in 1869. Nodular masses 
or concretions are arranged along the whole length of the shaft, but do not 
cover the whole surface. These nodes are made up of spherical or elliptical 
micrococci which eventually invade the cortical layers of the hair. While 
thus engaged, a gluey substance is developed which forms the bulk of the 
concretions and affords a home for the cocci. 

Treatment consists of frequent and thorough washings with soap and 
water and the application of corrosive sublimate, 1 : 2000 ; all being preceded 
by shaving. 

^ TINEA NODOSA 

This rare disorder of the hairs of the beard or mustache was first described 
by Cheadle and Morris. The root remains healthy while the hair shaft is 
covered with nodular masses consisting of a fungus which is composed of 
spores smaller than those of ringworm. The hairs are naturally brittle and 
split or break readily. 

The treatment consists in frequent shavings followed by the careful appli- 
cation of a mild and non-irritating parasiticide. 

PIEDRA 

Piedra is a nodular affection of the hair, in which mineral-like forma- 
tions are found irregularly distributed along the shaft of the hair. These 
are so hard that they make a rattling sound when the hair is combed. The 
disease is almost exclusively limited to Cauca in Colombia, South America. 
It is mostly confined to the hair of the head, chiefly of women, but occa- 
sionally affects the beard of men. It is non-contagious, but probably parasitic. 

Etiology and Pathology. — It is said that the use of a mucilaginous oil 
or water, by the native women in dressing their hair, favors the development 
of the disease. The essential cause is a fungus growth, which is evidently 
stimulated by the warmth of the atmosphere, as the affection is more prevalent 
in the warm valleys. Under the microscope the nodes are found to consist 
of spores, mycelia and filaments. The surface of the growths is darkly pig- 
mented and the affected hairs relatively small in size. 

The diagnosis is readily made from the stony hardness of the nodes, as 
compared with the nodular enlargements in tricorrhexis nodosa, or the nits 
in pediculosis capitis. Treatment by applications of hot water will com- 
pletely remove the nodes, and then avoidance of contributing causes would 
be probably sufficient to prevent a relapse, although the use of a hot corrosive 
sublimate solution 1 : 1000 may be necessary. 









CANITIES ! ' ! * 



CANITIES 

(Grayness of the hair; Blanching of the hair; Whiteness of the hair; Spi- 
losis poliosis; Poliotes, etc.) 

Acquired Canities. — Grayness of the hair, beginning after youth, is too 
common to excite much remark. It may appear suddenly or gradually ; affect 
the growth of a small part of the hairy surface, or become more or less general. 
In most cases the change of color of the hair is both permanent and slowly 
progressive; showing first on the head, often beginning about the temples, 
some time before gray hairs are seen in the beard. Exceptionally the beard 
may be first in the order of change or co-existent with the early whitening 
of the hair of the head. At a later period piliary growths on other regions 
of the body may lose their color. Earely whitening of the hair may be 
temporaiy when it arises through disorders of the nervous system. The author 
has seen one case of complete whitening of the beard during the development 
of organic brain disease, in which the original color was fully restored with a 
remission of the cerebral symptoms, and remained unchanged until death a 
few months later from the brain disorder. Sudden bleaching of the hair has 
been reported from depressing mental shocks, such as severe fright, grief, etc. 
Such cases must be extremely rare. Acquired canities beginning before thirty- 
five years of age is deemed premature. There is, however, normally great 
difference in families or even among members of the same family in this 
respect. Males strongly resembling the maternal parent may retain the color 
of the hair years longer than those bearing the strongest paternal likeness, and 
less frequently vice versa. 

Canities may be symptomatic to certain diseases which cause more or less 
temporary baldness; such as syphilis, alopecia areata, peripheral neuroses and 
leucoderma. 

Congenital canities may be a part of the general absence of pigment in 
the tissues known as albinism, or it may be unconnected with that condition, 
and occur only in patches amid the normal hued hair. A few cases have been 
reported of a peculiar alternate whitening of short sections of the hair ; between 
the white sections the color being natural and the hair otherwise normal. This 
condition has been termed ringed hair from its odd appearance. 

Etiology. — Age is an ordinary cause of canities after middle life, but even 
at this period as well as in the premature form causes which underlie dis- 
turbances of innervation or nutrition, such as worry, dissipation of various 
kinds, overwork and local injuries, hasten the change. Heredity is often a 
factor in premature canities, and probably a nearly constant influence in the 
congenital form. 

Pathology. — Grayness is due to one or both of the following processes : 
It is found that gray hair, especially beginning at the free ends of the hair, 
contains air in the cortex, which must have formed there or gained entrance 
from the atmosphere. Such hairs resume their natural color if deprived of 






100 PLICA 

air by means of the air pump. Commonly whitening of the hair begins at the 
root from failure of the papillae to produce or deposit pigment. Viewed from 
either the suspension of pigmentation or from the presence of air in the 
cortex of the hair, it is more than probable that the pathogenesis of canities 
is in the nature of a tropho-neurosis.* 

Treatment. — Most dressings recommended for the artificial coloring of 
gray or white hair are decidedly objectionable, and many of them dangerous. 

Kaposi recommends the following : 
To obtain a black color : 

1$. Argent, nitrat 3 1. 

Plumb, acetat gr. 15. 

Aq. cologn gtt. 15. 

Aq. ros ad. o 3. M 

To obtain a brown shade : 

1$. Acid pyrogal gr. 15. 

Aq. cologn 5 J. 

Aq. ros 5 1$. M. 

Leonard recommends : 

No. 1. 

1$. Bismuth, citrat 5 1. 

Aquae rosae, 

Aquae distil aa o 2. 

Alcoholis 5 5. 

Ammonias q. s. 

M. Sig. — Apply in the morning. 
No. 2. 

1$. Sodii hyposulph 3 12. 

Aquae distil '. o 4. 

M. Sig. — Apply thoroughly in the evening. 

Few people care to take the time to make themselves conspicuous by dyeing 
the hair in these days. Much can be done to prevent premature whitening of 
the hair by physiological methods to improve any existing impairment of vigor, 
and something also by the use of internal remedies. See indications for 
Graph., Kreosotum, Lycopodium, Plws. acid. 

PLICA 

(Matted hair; Polish ringworm; Plica polonica; Trichosis plica; Tri- 
choma, etc.) 

Plica is a condition of the external hair in which it becomes mechan- 
ically matted together with an admixture of dust and other substances, 

^Some changes in the color of hair other than whitening may be due to trophic in- 
fluences of a similar nature to the pathological origin of canities. This change is occasion- 
ally seen after general falling out of the hair from some acute or exhausting disease, when 
the renewed growth of hair is more or less changed in color. Circumscribed loss of hair 
may be followed by new hair of a different hue. This is observed quite often in the first 
hair growth after alopecia areata. Nervo-mental influences may, with extreme rarity, 
cause changes in the color of the hair. Most discolorations, however, are produced by 
the local action of chemicals. Occupations in which chemicals are largely used may cause 
changes in the color of the hair. Thus green hair is sometimes seen in workers of copper; 
blue hair on those employed in indigo works, or cobalt mines; black hair in miners of coal. 



A I .( >PECI A— A I.OPECI A A DXATA 



101 



and is allowed to remain so until the scalp becomes inflamed, infected with 
pediculi, or the mass is lifted away from the scalp by the growth of the 
hair. 

It is, therefore, purely the result of neglect and not a distinct disease, and 
occurs chiefly in the more ignorant districts of the Russian Empire. It is seen 
occasionally among emigrants from that country, and less frequently, and in 
a mild degree, among the uncleanly in this and other countries. 

Etiology. — The causes are lack of cleanliness and combing of the hair, 
together with a certain superstition among the lower class of Russian and 
Polish people, that the formation of a plica will prevent or cure other dis- 
eases. Neuropathic plica is a term given to a rare phenomenon manifested by 
the contraction of the hair of a limited surface into a tangled firm mass im- 
possible to unravel. Crocker mentions two cases which came on within a few 
hours after washing the hair in warm water. Nothing further is known 
regarding its etiology, but it is supposed to be of nervous origin. 

Treatment. — The masses of hair and dirt may be removed with the scis- 
sors, and any other disease of the surface found present treated according to 
its nature. If a superstition in regard to a plica is cherished by the possessor, 
it may be cleansed with some deodorizing oil, soap and water, and then un- 
tangled with comb and brush. Xervous plica may suggest such remedies as 
Borax and Vinca minor. 



ALOPECIA 

Definition. — A loss of hair, partial or general, from any hairy sur- 
face, but commonly affecting the scalp. There are four principal forms of 
alopecia: (1) A. adnata; (2) A. prematura; (3) A. senilis; (i) A. areata. 



ALOPECIA ADNATA 

(Congenital baldness.) 

Congenital absence of hair may be partial or complete, temporary or per- 
manent. It is a rare condition of the new born, nearly always temporary, 
and then due to a delay in the development of the hair, sometimes associated 
with imperfect development of other structures. Two or three cases have been 
reported where the condition was permanent, and in one, on examination of 
a section of the skin with the microscope, no hair follicles were found, but in 
the deeper portion of the corium rudiments of such structures were present. 
Rarely does the hair fail to grow after an interval of weeks, months or years. 

What is known of the causes and pathology may be summed up as heredi- 
tary influence and prenatal defect in nutrition and development. 

Treatment consists in the early administration of tissue remedies as 
indicated. See list of drugs for premature baldness. 



102 ALOPECIA PREMATURA 



ALOPECIA PREMATURA 

{Premature baldness; Alopecia presenilis.) 

Loss of hair before the fortieth year may be idiopathic or symptomatic. 
Idiopathic premature alopecia may begin as early as puberty, but not com- 
monly much before the thirtieth year. At whatever period before middle age 
it begins, there is no apparent cause. There is usually at first an increase of 
the normal shedding of the hair, commencing, as a rule, about the temples and 
vertex. The hair may be reproduced, but is less vigorous with each reproduc- 
tion until it ceases to appear. Sometimes the hair line at the sides of the 
forehead gradually recedes, sparing a central crest for a time longer and 
forming the arched forehead; or the whole forehead line maj r recede forming 
a high forehead. Frequently the hair becomes thin over the whole crown at 
the--same time, or it may extend from the vertex forward. The resulting 
baldness is nearly always symmetrical. Occasionally there will be a temporary 
increased growth of hair. Left untreated, usually progressive thinning of 
the hair is not long delayed, though it may be very gradual. Less often the 
progress to baldness is rapid. Grayness of the hair does not precede it, as 
a rule, and the hair on sides and back of the head may remain unaffected. 

Symptomatic premature alopecia may be temporary or permanent, de- 
pending on the nature of the pre-existing local or general disorder, which 
operated to cause it. The larger number of cases give a history of antecedent 
seborrhceic disorder, commonly called dandruff (Alopecia furfuracea seu 
pityrodes). Constitutional states which are often productive of baldness are 
the acute fevers, erysipelas, abuse of mercury, cachexias from such diseases as 
diabetes nielli tus, phthisis, syphilis and leprosy (Defluvium capillorum). 
Continued mental anxiety and nervous shocks may also produce baldness. 
The loss of hair may begin during the coiirse of disease or not until convales- 
cence in the more acute affections. Commonly there is only a thinning of the 
hair, which may affect other hairy parts as well as the scalp. The hair is some- 
times shed rapidly, at other times slowly and persistently. In most cases the 
baldness is temporary. 

Local forms of permanent loss of hair may result from lupus erythematosus, 
scleroderma, folliculitis decalvans, the ulcerative lesions of syphilis, kerion, 
favus and sometimes from seborrhcea, which destroy the hair follicles (Alo- 
pecia follicularis) . Local forms of temporary baldness may come from con- 
tinued inflammation of the scalp in eczema, psoriasis, etc., parasitic affections, 
and from superficial local injuries. 

Etiology and Pathology. — Family tendency to baldness has been found 
to exist in nearly fifty per cent, of mixed cases of idiopathic alopecia prema- 
tura. In women the per cent, of heredity is much larger, though women are 
much less affected with baldness than men. This is accounted for by the 
greater abundance of fat in the scalps of females, more care given to tbeir 
hair, and the lighter and less close covering of the head worn by that sex. 






ALOPECIA PREMATURA 



103 



General differences in the occupation and habits of the two sexes probably 
exert an influence also. The daily application of water to the scalp, which is 
a habit with a large number of patients, contributes to alopecia. Brain work- 
ers and intellectual people are more often afflicted than the opposite types. 

Pathologically, premature loss of hair is one of atrophy, both of the con- 
nective tissue of the scalp and of the hair producing structures, consequent to 
a diminished blood supply. Pincus is quoted as believing that the change is 
one of hypertrophy of the connective tissue, which by contraction compresses 
and leads to atrophy of the hair follicle. He also believes that in cases not 
due to heredity, chronic inflammation of the scalp in the years before 
puberty is the most active pathological cause. Seventy-five per cent, of the 
editor's cases have been due to seborrhcea in some form, so the microbacillus 
of Sabouraud may easily exert a large pathological influence. The etiology 
and pathology of cases of symptomatic alopecia vary with the nature of the 
antecedent diseases. 

Diagnosis. — Age of occurrence, symmetrical distribution and absence of 
any history or evidence of previous local disease serve to distinguish the 
idiopathic form. The recognition of the symptomatic form rests on a knowl- 
edge of the pre-existing diseases. Asymmetrical loss of hair may be differen- 
tiated from alopecia areata by the absence in the history of the latter of any 
related disease and by the sudden discovery of round or oval, smooth patches 
nearly or quite free from hair. 

Prognosis. — Progressive loss of hair can often be arrested by judicious 
treatment in the early stages of the idiopathic variety. Marked hereditary 
tendency to early baldness and atrophy of the scalp are unfavorable features. 
Quite a large proportion also of cases of the symptomatic form may be cured 
or arrested by suitable treatment. If due to diseases attended with change 
of structure, specially of the hair follicles, the piliary growth is not likely to 
be restored. 

Treatment. — Physiological methods should be employed to correct any 
general or local impairment of nutrition. These may relate to diet, habits, 
etc., and to local care of the scalp. Preventive treatment by any of these 
is often most satisfactory, and may sometimes postpone for a long time a 
hereditary tendency. Vigor of the hair is promoted by air and light, hence 
a covering for the head should only be worn when needed for protec- 
tion, and then should be as light as practicable and suitably ventilated. 
The surface of the scalp should be cleansed occasionally as needed by lather- 
ing it with any non-irritating soap. Agnine soap, made from the fat of lamb's 
wool, the author prefers to all others. After the scalp has been well rubbed 
with the lather, using the ends of the fingers, it should be rinsed off with clear 
water, and then dried with a warm bath towel, by artificial heat, by an open 
fire, or by sitting in the sun; when dry, the surface of the scalp should be 
lightly anointed with sweet almond oil, or better, with four parts of the 
latter to one of lanolin. The less elegant olive oil or vaseline can be used for 
the same purpose. It is important that they be applied in small quantity, 



104 ALOPECIA PREMATURA 

just sufficient to replace the natural secretion which has been removed by 
cleansing. The hair may be straightened into place with a comb, but not 
brushed until some hours later; the object being to keep the oil upon the scalp 
and not brush it upon the hair. If needed, the oily application can be em- 
ployed every, few days to keep the scalp from becoming dry. Frequent or 
unnecessary cleansing of the scalp is to be avoided. Singeing is abso- 
lutely contraindicated, and wetting the hair with water should never be 
practiced. If systematic care of the scalp and other physiological meas- 
ures, together with the indicated remedy internally, do not arrest prema- 
ture falling of the hair, local stimulation may be tried. For its stimulating 
effect ammonia may be substituted for soap in cleansing the scalp, in the 
proportion of one part of liquor ammonise to nine parts of water. The sub- 
sequent course is the same as after the use of soap. An oil may be combined 
with a local stimulant to be used in place of the simple oil, as in the fol- 
lowing.: 

R. 01. ricini 5 4. 

Spr. vini rect o 8. 

M. et add. 

Tinct. eantbaris 5 2-5. 

Aq us rosffi o 2. M. 

Either oil of turpentine, tinct. of capsicum, nux vomica, or jaborandi, or 
pilocarpine, resorcin, quinine or salicylic acid may replace the cantharis, some- 
times with advantage. Cologne or lavender water may be substituted for rose 
water or other perfume added when desired. Listerine, saturated solution of 
boracic acid or lavender water may be si ostituted for the alcohol. Applica- 
tions compounded with many ingredients are usually to be avoided. 

Massage of the scalp should be done by grasping the scalp laterally and 
then in all other directions, with the hands, so as to move the entire surface 
at once. This procedure loosens the scalp, increases the circulation and stimu- 
lates pilary growth. The same can be accomplished with vibratory massage 
or with the milder high frequency currents, but each patient should manipulate 
his own scalp, night and morning for two or three minutes regardless of 
other stimulating treatment. Faradic electricity presents no advantages over 
the high frequency currents, and the results achieved with the latter in the 
editor's hands far surpass the questionable value of the former. 

For symptomatic alopecia the nature and expression of the causal dis- 
ease will indicate the line of treatment, and the student is referred for de- 
tails to articles on seborrhoeic dermatitis and. other local affections named as 
related to this type. In the absence of active local disease the same methods 
of attention to the scalp may be called for as mentioned under surface treat- 
ment of idiopathic premature alopecia. In addition to remedies adapted to 
the several causal states, see indications for Cal. carb.. C. phos.. Baryta carb.. 
Fluor, acid, Helleb., Hypericum, Ercsot.. Kali sulp.. Lycop.. Merc. riv.. Xat. 
mur., Nit. acid, Pet., Phos. acid, Sarsap., Selcn.. Sepia. Sulph., Staphisag., 
Thuja and Vinca. 




Fig. 32— COMPLETE ALOPECIA 



Patient, an American boy of three years. The first evidence of alopecia areata 
appeared as a small smooth patch in the interparietal region, which extended per- 
ipherally for six months until all the hair of the scalp, eyebrows and eyelids had 
been lost. This case was of an undoubted neurotic basis, and while under the influ- 
ence of phosphorus, sixth decimal, showed marked improvement. 




Fig. 33— ALOPECIA AREATA 

Patient, an Irish lad of seven. Duration, one month. A small patch in the 
frontal region, coalesced with a large patch in the interparietal region, forming an 
irregular elliptical area covered with a brawny seborrhceic scaliness. Although there 
was a history of ringworm of the same region, some six months previous, no evidences 
of the fungus could be found microscopically at the time of the alopecia. Phos- 
phorus, sixth decimal, was given, and also a weak solution of resorcin in alcohol was 
applied for six weeks with a complete cure as the result. 




ALOPECIA SENILIS— ALOPECIA AREATA 106 



ALOPECIA SENILIS 

(Senile baldness.) 

Symmetrica] loss of hair occurring after the fortieth year is usually a part 
of the beginning atrophy incident to age, and often affecting other structures 
of the skin and organs of the body as well. As years do not measure exactly 
the structural age of tissues, so the baldness of old age varies widely in the 
year of its approach. The same causes and conditions which produce prema- 
ture loss of hair may operate at what is termed the senile period of life in some 
instances. Usually the loss of hair is limited to the scalp, but it may affect 
any hairy surface. As a rule it begins at the vertex and spreads forward and 
backward until the whole crown is affected. It may, however, appear as a 
general thinning of the hair of the whole crown or it may begin at the 
brow (more like premature alopecia), and show its advance by the receding 
forehead. Senile baldness may be, or not, preceded by grayness of the hair. 
As a rule, the hair on the back and temporal regions of the head is retained, 
owing probably to the greater thickness of the scalp in these regions, and its 
more constant exposure to light and air. This is true in some degree as to 
the whole scalp in women, and accounts for their much greater freedom from 
baldness at all ages. 

Etiology axd Pathology. — Any influence which tends to hasten atrophy 
of the tissues of the body generally, the skin and especially the scalp, may 
cause senile alopecia. An associated seborrhcea is not uncommon. The patho- 
logical effect of the beginning atrophy of the skin and subcutaneous tissue is 
to cripple the vascular supply of the hair follicles, until ultimately, with 
the cessation of the capillary circulation, their power of production is entirely 
lost. 

The prognosis is only exceptionally hopeful before the atrophic stage. If 
the affected scalp is thinned and adherent, little can be done to stay the loss 
of hair. After atrophic baldness of old age, as after loss of teeth and vision, 
renewal occurs with extreme rarity. 

Treatment. — In hopeful cases the same measures of treatment and in- 
ternal remedies may be employed, and on the same indications as for prema- 
ture alopecia. 

ALOPECIA AREATA 

(Alopecia circumscripta; Tinea decalvans; Porrigo decalvans; Area celsi.) 

Definition. — An acute complete circumscribed baldness, occasionally 
spreading over comparatively large areas, but commonly limited to the 
scalp, without any apparent change in the skin. 

Symptoms. — Alopecia areata occurs suddenly, as a rule, without any local 
sensations (or sometimes with a moderate itching), in small, roundish spots 
on an apparently otherwise sound skin. There may be found one or more 
whitish, smooth spots entirely denuded of hair; they are nearly always dis- 



106 ALOPECIA AREATA 

tributed without regularity, but frequently in males they begin about the 
occipitoparietal regions of the head. The disease in men may affect the beard, 
or the eyebrows, axillae, pubes, and even the downy surfaces in either sex. Ee- 
newed growth of hair may appear on the bald spots in a short time ; they may re- 
main stationary, or most often they increase in size, and then always by 
peripheral extension. This is a characteristic of the spread in the area of 
the individual spots in true alopecia areata. Such growth in size may keep 
to the roundish shape, become oval, or by union with other patches form ir- 
regular areas of baldness; occasionally the growth of a patch is principally 
aX one or more sections of the periphery, forming single, or, if multiple, 
zigzag extensions in several directions. Earely the disease may spread in 
a band, like a girdle, around the head just within the hair line. The patches 
of skin denuded of hair appear polished, thinned, less firm than normal and 
sometimes slightly depressed. Sensitiveness to irritants is diminished over 
the -affected area to a considerable degree, and, though Neumann declares the 
spots ma}' be anaesthetic, appreciable loss of tactile sensation must be very 
rare. At the border of a spreading patch there can be found short hairs, 
which come out with the slightest traction upon them, and some long hairs 
near the border can be extracted with ease. The short hairs appear largest 
at their distal extremities, due to their having broken off near the surface, 
and the last portion of the hair extruded is reduced in size from lack of nu- 
trition. Occasionally these short hairs may be seen in small number on the 
central part of the patch. When a patch ceases to spread the short hairs do 
not appear, and the long hairs are not so easily pulled out. The after course 
varies widely. In some cases the bald spots become smaller by a growth of 
hair at the periphery; in the most favorable cases hair may appear all over 
the patch at once. This new hair is usually fine and lighter colored than 
the normal hue of the hair, and sometimes it is white. Frequently the 
downy hair falls out again, to remain absent for a longer or shorter period, 
before it is renewed, when the color is apt to be a step nearer the normal shade. 
Shedding of new hair growth may be repeated several times before it becomes 
permanent. The return of pigment to the hair may be observed sometimes if 
watched closely; first showing near the scalp as the hair grows out, the distal 
ends of the hair continuing lighter in color. Occasionally as the hair is re- 
stored to one or more patches, others may appear. In persons under forty- 
five or fifty ultimate recovery is the rule; incomplete recovery is not infre- 
quent, though sometimes only a downy growth ever appears. Earely the 
alopecia is permanent, and then chiefly in the latter half of life. Eecurrences 
are quite common and the same spots maj' be affected a second time. Other 
portions of the body besides the scalp may be attacked at the same time, and 
with great rarity the whole hairy surface may be involved. 

A comparatively rare form of circumscribed baldness occurs in pea to 
bean sized patches in which the scalp is left white and resembles scar tissue. 
There may be one or many spots. In the mildest form the hair about the 
patches is not loosened; and the patches once formed show little tendency to in- 



ALOPECIA AREATA 107 

crease in size, but may multiply in number. Efforts to renew the growth of 
hair on the spots are not often successful. In a still more rare and severe, 
variety, the spots are markedly depressed below the surface and may show 
a diminished sensitiveness. While there are no short hairs at the periphery 
of the patch the long hairs at the border are easily extracted. Evidently the 
pathological cause is too deep-seated or rapid to permit the growth of hair 
stumps. New hair is not reproduced. The nails of the hands and feet may 
become affected by the disease. The latter variety is described by Neumann 
as alopecia circumscripta seu orbicularis. It may have no relation to the mild 
variety except in the probable neurotic pathogenesis of each. 

Another form of local neurotic alopecia results from traumatism, or from 
some functional or organic change in the course of a nerve, such as local injury, 
neuralgia and neuritis. In this type of alopecia, the patches may be linear 
or in irregular shapes, and not uniformly round or ovoid as in the primary 
patches of true alopecia areata. Neither do they regularly spread by the char- 
acteristic loosening of hairs at the periphery, as in the latter, and the new 
growth is more likely to be permanently gray or white. 

Etiology and Pathology. — The clinical history giving the onset, mode 
of extension and changes in the hairs at the periphery of a patch of ordinary 
alopecia areata leaves little room for doubt as to the parasitic nature of most 
cases of the disease, but that a number of the cases are neuropathic in origin 
is indisputable. 

The disease is most common in the first half of life and among the poor, 
though seen in all classes of people. In a large number of cases contagion, 
while not virulent, stands as a probable cause. Hillier, in his hand-book, 
mentions the occurrence of the disease in a school of over a thousand pupils, 
in which it attacked only the girls living in one block; one child was found 
to have had the disease for some time, while forty-three were suddenly 
affected. Their ages varied from seven to fourteen years, and the number 
of spots on each child from one to three. Outbreaks of the disease among 
the French soldiers have been reported at different times, and ascribed to 
the common use of the same scissors or clippers in cutting the hair. The 
proportion affected among some regiments stationed in Paris was said to have 
been over one per cent, in 1892. Crocker reports the disease as occurring 
in eight children of one family. The governess of the children had the 
disease later, and she in turn communicated it to an elder sister by sleeping 
with her. Eichhoff mentions ten cases among the patrons of one barber. 
Instances of the disease affecting two or more persons more or less intimately 
associated together are not rare. 

As to the nature of the infecting organism, there is much doubt. Hutch- 
inson and Crocker, of London, believe, as a result of much clinical observa- 
tion, that true alopecia areata is related to ringworm, while other observers 
ascribe it to other fungi or to micro-cocci which they have occasionally found. 
Hutchinson says that ringworm in childhood may result in alopecia areata 
in adult life. Crocker entertains the view that alopecia areata in adults is 



108 ALOPECIA AREATA 

equivalent to tinea trichophytosis in children. Fungi similar to those of 
ringworm have been occasionally found in cases of alopecia areata, but the 
evidences of the relation of the two diseases is mainly inferential ; an example 
of the basis for this is the fact that in countries where alopecia areata is most 
common, so also is ringworm. It is recognized by all that the tinea tonsurans 
does sometimes produce circumscribed alopecia, but then the etiological 
cause and pathological result are most evident and the effects of treatment 
sustain the relation. Sabouraud believes this disease is due to the same micro- 
bacillus that he found in acne, comedo and seborrhcea and further considers 
it a form of seborrhcea oleosa. 

Probably a larger proportion of the cases of alopecia areata seen in this 
country are of the neurotic type than of the continental cases. Hence it is 
that some of the American writers, notably Duhring and Bulkley, hold to 
the view of the neurotic origin. However, some cases undoubtedly are due 
to tropho-neurotic factors. The generalized or universal form of alopecia is 
'probably of this nature; or it and other varieties may be both neurotic and 
parasitic in some instances. There are grounds for looking upon nerve dis- 
turbance as largely predisposing rather than an essential cause in all except 
true trophoneuroses. 

The pathological changes found in alopecia areata are, according to Eobin- 
son, due to inflammation in the corium, with round cell infiltration and thick- 
ening of the walls of the vessels of the affected part. Consequent interference 
with the nutrition of the hair results in atrophy of the hair producing struc- 
tures. He attributes the inflammation to the presence of a micro-organism. 

Diagnosis. — Symptomatic forms of limited baldness may be excluded 
by the history of antecedent disease, such as favus, lupus erythematosus, 
syphilis, etc. Bearing in mind the usual features of true alopecia areata — the 
smooth white spots completely denuded of hair, growth by peripheral exten- 
sion, short, club-shaped hairs at the margin, which, with some adjacent 
long hairs, are easily extracted — no difficulty will ordinarily be found in dis- 
tinguishing this disease. Circumscribed alopecia from injury, etc.. to nerve 
branches may have the same surface appearance as the typical form, but the 
absence of the_ characteristic hairs at the periphery and the difference in the 
apparent mode of occurrence and extension suffice to differentiate one form 
from the other. The small spots of the orbicular variety may always be known 
by their depression below the surface and the absence of the characteristic 
hairs at the border. Ringworm patches with baldness ordinarily sbow the 
presence of scales, and short, twisted hair may be found scattered over the 
surface. The short hairs or the long hairs at the margin of the patch are 
not extracted so easily as in alopecia. In doubtful cases the microscope 
should be employed to search for the fungi of tinea trichophytosis. 

Prognosis. — Most cases of alopecia areata occurring before middle life 
are likely to recover under proper management. The older the patient, the 
larger the area involved, and the longer the duration the less chance of re- 
covery. "When there has been no visible sign of hair over the affected portion 




Fig. 34.— ALOPECIA AREATA 

Affected area represents coalescence of several patches. Bilateral; duration three [months. 
Cured under the internal use of phosphorus, third decimal. 







H ^B^"'*' jp' j^| :^^^Bai \ " 




^F- 


A 


,« 

*/ 


R ^ V^B 


* 


. 



Fig. 35.— ALOPECIA AREATA 

Permanent localized symptomatic variety of the crown of the head of a young 
woman from lupus erythematosus. 




Fig. 36.— ALOPECIA AREATA 

Temporary localized symptomatic variety of the back of the head of a young girl from 

impetiginous eczema. 



, 



ALOPECIA AREATA 



10!) 



for a year or more, and the skin has become atrophied, there is little pros- 
pect of recovery, though a new growth of hair is possible. In the eases due 
to nerve disturbance the hair generally grows in again, but it may not regain 
a normal color. In circumscribed orbicular alopecia no regrowth of hair is 

to be expected. As to time of recovery in hopeful cases, it may vary from 
two months to two years. 

Tkkatment. — The method of treating alopecia should depend on the 
essential pathogenesis of each case. If neurotic in nature internal medication 
will accomplish alone, I believe, all that any treatment can. If, as in a large 
majority of cases, there is found the clinical signs of a parasitic disease, and 
it is remembered that pathological histology has shown that in such cases 
inflammation exists in the inner parts of the skin, the indications are to both 
give the internal remedy and to employ a penetrating parasiticide locally 
capable of exciting a mild grade of inflammation. At all events I have 
found the application of these therapeutic principles to work very well in results. 

In the local treatment of the ordinary form of alopecia areata thorough 
cleansing of the affected area, and then of the whole scalp, is the first step. 
This may be done with tincture of green soap made into a lather with water, 
which, after being thoroughly rubbed into the surface, is then sponged off 
with tepid water and the scalp quickly dried. Dilute liq. ammonia may be 
substituted for the soap for cleansing purposes, and sometimes chloroform or 
ether may be used to cleanse the affected area and surrounding surface, to 
facilitate the penetration of the germicide to follow. A single thorough ap- 
plication of carbolic acid to moderate sized patches, followed in a few days 
by the persistent application of a one per cent, ammoniated mercury ointment 
daily, has been found beneficial in several cases. Formalin one part to fifty to 
two hundred of water, lactic acid and water, equal parts or full strength, and 
trikresol and alcohol, equal parts or full strength, have all given satisfaction; 
care being taken not to push these caustics to the point of exciting an acute 
inflammation. The loosened hairs about the margin of the bald patch may be 
removed by gentle traction with the fingers or forceps, and the parasiticide ap- 
plied over the patch and a little beyond its border. One of the best applications 
in the early stage is -iodine one part to thirty parts of collodion, painted on about 
every four days, or as soon as the preceding application is thrown off. If 
much irritation is produced, the strength can be reduced, or it can be re- 
placed with a milder antiparasitic in ointment or oil ; salicylic acid thirty grains 
to two ounces of castor oil, perfumed with a few drops of oil of rosemary serves 
this purpose. Corrosive sublimate in lotion or ointment may be adapted to 
some cases. Choice may be made of the following : 

IL Hydrarg. bichlor gr. 2. 

Spr. vini rect o i. 

Aq. cologn 5 2. M. 

or, 

IL Hydrarg. bichlor. gr. 1. 

Lanolin o J. 

01. ainagdalse dulc 5 1. M. 



110 FOLLICULITIS DECALVANS 

Either of the above may be rubbed onto and about the bald patch twice 
daily. 

In severe or intractable cases chrysarobin may be employed: 

1$. Chrysarobin gr. 25. 

Vaseline B 1. 

M. Sig. — Apply night and morning. 

or, 

1$. Chrysarobin gr. 20. 

Traumaticine 3 1. 

M. Sig. — Paint over the affected area every second to fourth day, as needed. 

The objections to chrysarobin are its disfiguring stains and its tendency 
to produce dermatitis. It should, therefore, not be used in conspicuous loca- 
tions, and never without due caution. 

The Ebntgen rays have cured stubborn cases for the editor when all other 
means failed; the exposures being at a distance of twelve inches, for four 
to ten minutes about every four days. Radium in the activities now obtainable 
presents no advantages over the X-rays. Phototherapy as recommended by 
Finsen and others has been used with favorable results by a number of 
authorities. The treatment is tedious, especially if there be many areas. 
The patient should be exposed for twenty minutes to an hour every second or 
third day. The fact that hypertrichosis has developed upon arms of those 
attendants exposed to the rays may be considered encouraging. As a routine 
measure, the editor applies the Oudin or Piffard type of high frequency cur- 
rents to all cases of alopecia areata, twice weekly when possible for one to 
three minutes. Faradic and galvanic electricity are seldom used in this 
disease at the present time. 

If there is any departure from the standard of general health, physiological 
methods should be employed to restore nutrition or tone. Each case must 
decide the choice of means in this line of therapeutics, as it must also in 
the selection of a drug for internal use. See indications for Cal. phos.. Fluoric 
acid, Phos., and Vinca minor. 



FOLLICULITIS DECALVANS 

(Acne decalvans; Folliculite epilante, etc.) 

So many clinical forms of inflammation of the follicles or peri-follicular 
tissue resulting in cicatricial alopecia have been described and named in re- 
cent years that there is much confusion as to the actual clinical limits of 
this rare disease. Thus at one extreme there is no positive sign of inflamma- 
tion; at the other, considerable pustulation. The one constant feature is the 
termination in apparent or real scar tissue, and nearly always permanent 
loss of hair in the affected area. The same pathological resiilts follow other 
diseases which have more marked clinical features in other respects, and are 
differently classed. Probably all forms of this disease are of parasitic origin. 

The mild form resembles alopecia areata. It occurs in patches not usually 



FOLLICULITIS DECALVANS HI 

exceeding a silver quarter in size. The surface affected may be pinkish in 
color, and about the hair of an affected follicle there may be found a pin-head 
deeper redness. The hairs can be easily removed, but are not swollen, twisted 
or broken. Left alone, they fall out spontaneously, the redness subsides and 
is succeeded by atrophy and a depressed scar. The patches spread in an ir- 
regular way; they may be grouped or several distinct patches may be found 
on different parts. A few follicles in the diseased area may escape leaving 
normal hairs; or the baldness may be complete with an ivory-like look of 
the surface, which is frequently depressed. 

This form may be diagnosed from alopecia areata by the lesions about 
the hairs, the slight diffused redness of the surface, and by an absence of the 
short, club-shaped hairs at the periphery usually found in the latter dis- 
ease. 

In another form, folliculite epilante of Quinquaud, the loss of hair in 
spots is usually first noticed. On inspection, small pustules are found perforated 
by hairs, which are easily removed or later fall out spontaneously. In place 
of the pustules there may be sometimes seen papular-like follicular eleva- 
tions, and sometimes crusts covering a secreting base. The lesions appear in 
crops, isolated, and few in number. After the hair falls out, the follicle and 
other parts of the skin undergo pathological change resulting in cicatricial 
tissue formation, and permanent alopecia in irregular circular patches about 
one inch in diameter, more or less depressed and scattered over the scalp. The 
disease may occur very rarely on the bearded part of the face, axilla or pubes. 
Two cases under my observation were both situated on the scalp; one 
showed a predominance of pustular lesions, the other of papular. 

Several minor and still rarer forms of cicatricial alopecia have been de- 
scribed chiefly from the original reports of Besnier. Their extreme rarity, 
and the uncertainty as to the alopecia being due to a folliculitis, or if so, 
that they may be variations from the more common types, does not warrant 
more extended notice of them here. 

The pustular form of folliculitis decalvans may be readily diagnosed by 
recalling its clinical characteristics. It might be confounded with sycosis, 
or a pustular syphilide. Coccogenous sycosis is known by the location on the 
bearded portions of the face, its nodules, larger pustules and signs of infiltra- 
tion of the skin, with less tendency to produce alopecia. A pustular syphilide 
may be recognized by the ulcer underneath the dried pus, the distinct and 
elevated rim of the ulcer, and other obtainable evidences of syphilis. 

Treatment. — The same methods of treatment as are indicated for the 
parasitic type of alopecia areata may apply to folliculitis decalvans. Absolute 
cleanliness of the whole scalp, followed by daily painting on and about the 
patches of tincture of iodine, for two days or longer as advised by Quinquaud, 
may be effective. Baldness due to the severe form cannot be relieved. Graph- 
ites and Kali bromatum should be studied as remedies. 



112 DERMATITIS PAPILLARIS CAPILLITII 

DERMATITIS PAPILLARIS CAPILLITII 

(Sycosis capillitii; Sycosis framboesia; Acne keloid, etc.) 

Under this name Kaposi first described an anomalous form of disease in 
1869, and briefly mentions it in the last edition of his work on Diseases of the 
Skin in 1895, in the part of a chapter headed "Sycosis," though he says he 
has proved it does not begin as follicular pustules, and, therefore, it is not a 
sycosis. 

Its place in a pathological classification is not conclusive, although it 
has been classed as a form of folliculitis decalvans. 

According to Kaposi, the disease begins with pin-head, isolated papules 
at the border of the hair at the back of the neck. Subsequently the papules 
become aggregated, coalesce and form keloid-like, firm, projecting, pale or 
rejlmasses. Some are entirely bald, on others there remains twisted and matted 
hair which cannot be extracted with ease, or breaks off in the attempt. Small 
scattered pustules may be seen here and there. If the growths are incised, 
the knife makes a creaking sound and the exposed surface bleeds from many 
points. Commonly the disease spreads up to the vertex and may be limited 
to that location. As the disease extends up the occiput, fungating, frambcesi- 
form vegetations appear, from between which a very offensive secretion is 
discharged; they become crusted over and the occurrence of multiple abscess 
at different points undermines and in some degree destroys them. Finally 
after years they degenerate into sclerotic tissue with resulting destruction of 
the hair follicles and baldness, with sometimes tufts of hair left in places. 
These excrescences are due to papillary growths, histologically of the same na- 
ture as granulations, and it is believed they are not always due to the same 
kind of preceding lesion. Crocker mentions a case as following a probable 
outbreak of furuncles. 

The cause of the disease is not known, but it owes its special form to its 
anatomical location. 

A diagnosis can only be made by a knowledge of the full history of a case, 
showing the features already mentioned. If its peculiar secondary develop- 
ments follow as a sequel of other primary lesions, a differentiation must be 
established between diseases exhibiting a somewhat similar efflorescence. The 
prognosis is said to be good as to the general health, but the disease is 
intractable to treatment and liable to recur; the alopecia is permanent. 

Treatment. — Strict antiseptic cleanliness, a healthy environment, some 
tissue remedy, such as fluoric acid or its salts or calcarea sulp.. would seem 
indicated. Linear scarification, electrolysis and excision, have all been com- 
mended, but the recent successful use of the Rbntgen rays in arresting the 
active process and causing a partial disappearance of the lesions of this dis- 
ease, would point to this last method of treatment as being the most promis- 
ing. 



CONGLOMERATE SUPPURATIVE PERIFOLLICULITIS H3 

CONGLOMERATE SUPPURATIVE PERIFOLLI- 
CULITIS 

Under this name have been deseribed several suppurative follicular af- 
fections of the skin, having a certain resemblance, but not beyond a doubt 
of the same nature. 

In ordinary type it is an acute affection running its course in a few weeks, 
ending without fixed tissue change of the skin, or at most slight scarring. 
This form commences as a round or oval patch of moderately elevated skin, 
one-half to two inches in diameter, of a reddish-purple or bluish color. The 
surface may be partly crusted over or nearly smooth; a number of very 
minute to pin-head sized openings appear on the surface and a larger num- 
ber of whitish-yellow dots indicate the sites of other orifices in process of 
forming. From the small openings pus can be pressed out. 

In a more pronounced form, there may be a resemblance to carbuncle, 
with moderate fluctuation, but there is an absence of constitutional symptoms, 
no involvement of the lymphatic glands, and locally no necrotic core, forms. 
The hairs, if present, appear healthy though easily removed. 

The lesion is usually single, rarely multiple ; and most often appears upon 
the back of the hands and on the buttocks, but may occur on other parts. The 
skin of the patch may remain discolored, of a brownish hue, for some time 
after other signs of the disease have gone away. 

It would appear from descriptions of the disease that either of the above 
forms may assume the characteristics of other coccogenous dermatoses. Thus 
sycosiform, carbuncular, or phlegmonous features may develop, and thereby 
change the course, if not the nature of the diseased process, which may then 
be obstinate and protracted under treatment. Papillomatous growths on the 
surface of the patch are said to be a rare departure from the usual appearance. 

The etiology points to contagion. Quinquaud believes the active cause 
to be the staphylococcus pyogenes albus. Those who work among animals, 
especially horses, seem to be especially fit subjects for this disease. Patho- 
logically the process is a suppurative perifolliculitis of both the hair fol- 
licles and the sebaceous glands ; probably limited in most cases to those parts, 
occasionally involving other structures and assuming a likeness to other dis- 
eases. 

The prognosis is good under suitable management, and treatment con- 
sists of cleanliness, dressing the diseased surface with a mild antiseptic oint- 
ment of boric or salicylic acid, or lotions of formalin one per cent, in water, 
creolin two per cent, in glycerine, or ten per cent, of succus calendula in 
glycerine, and the administration of a remedy to control suppuration. See 
indications for Calcarea sulph.. Kali brom. and Petroleum. 



114 ONYCHAUXIS 



D. DISEASES OF THE NAILS 
ONYCHAUXIS 

(Hypertrophy of the nail.) 

Onychauxis or hypertrophy of the nail is an excessive formation of the 
substance of individual nails, whether this be manifested in an increase in 
the thickness of the corneous tissue, or an abnormal growth in any of its 
diameters. In the first form the unusual aggregation of nail-cells results in 
a hard, thick, opaque, misshapen nail, its surface glossy and grayish-white in 
color, and curved particularly at the free border, upward or downward. In 
the second variety, the deformity may be from lateral or longitudinal growth. 
The lateral hypertrophy produces the condition known as ingrowing nail, 
chiefly observed in the toes. The down-curving border often buries itself deeply 
in the adjacent tissue, causing an extreme sensitiveness of the soft parts, even 
proceeding to suppuration and the production of exuberant granulations. 
Such inflammation of the soft tissues and sometimes extending to the bone 
is termed paronychia (whitlow). This condition is often aggravated by undue 
lateral pressure from the shoe on the soft parts. 

Longitudinal increase may occur to an extent of several inches, and is 
usually associated with a downward bend, presenting all varieties of appear- 
ance between a claw-like curve and a ram's horn spiral twist. This distortion 
is termed onychogryphosis (curved nail). Such nails are dirty yellow, brown- 
ish or grayish in color, and ribbed or striated longitudinally or transversely. 
Their under surfaces are brownish, flak)', and marked by depressions between 
well-defined ridges. The effect of these conditions upon the hands, where they 
are fortunately rarely found, is not only disfigurement, but the sense of touch 
is diminished or destroyed, and capacity for fine work suffers. In the toes 
this deformity may render walking difficult, or even impossible. Lateral ony- 
chauxis may produce ingrowing nail or even lateral paronychia. 

Etiology. — Onychauxis may be congenital or acquired. If the former, 
the nail is relatively but slightly larger at birth, but continues later to grow 
with disproportionate rapidity. This is particularly found associated with 
ichthyosis, papillary enlargement, or congenital syphilis. Acquired ony- 
chauxis, either idiopathic or symptomatic, is far more common. Trauma, from 
the constant pressure of ill-fitting shoes, causes increased blood supply, and 
consequent hyperplasia. Unrestrained growth, as in the aged and bedridden 
by neglect, or in the Chinese by cultivation, is often connected as a cause, with 
lack of cleanliness, where the accumulation produces hyperplasia by its me- 
chanical presence. The nail and matrix may be involved in the spread of some 
chronic inflammatory process of the skin, as psoriasis, chronic eczema, lichen 
ruber, elephantiasis, leprosy and tuberculosis. Said diseases, however, will 
not cause onychauxis unless predisposition to it exists; for frequently the nail 
is not involved at all, or even atrophy may occur. S} r mptomatically, onychauxis 



ONYCHOMYCOSIS 115 

is seen in degenerative or irritative neuropathic affections, particularly in 
spontaneous neuritis, neuralgia, chronic myelitis, syringomyelia, etc. It is 
also found after certain chronic bone diseases. Partial hypertrophy follows 
ulcer of a portion of the nail bed, resulting from efforts of the intact matrix 
to compensate for the deficient function of the ulcerated portion. 

Prognosis. — This depends upon the curability of the antecedent general 
disease. If the morbific influence, be it inflammatory or mechanical, can be 
removed before the matrix is irrevocably degenerated, improvement or cure 
may be expected. Congenital disease of the nails calls for a guarded prognosis, 
while in lepra or elephantiasis, or extreme traumatism, the condition of the 
nail is often hopeless. 

Treatment. — This should be directed toward the removal of the cause 
or the antecedent disease, and where the nail condition is the result of any par- 
ticular disease, the treatment is the same as called for by the general condition. 
If a condition of ingrowing nail exists, or inflammatory changes resulting 
therefrom are found, treatment must first deal with that. In aggravated 
cases, with much hypertrophy of the soft parts, I have removed, under anaes- 
thesia, a considerable portion of the latter with one cut of the knife. The 
wound was allowed to heal by cicatrization, which by contraction entirely freed 
the nail and gave a permanent good result. Less radical treatment will often 
suffice, such as softening by soaking in hot alkaline solutions, and then scrap- 
ing the nail thin in the centre, destroying (under cocaine) the granulations 
with nitric acid or nitrate of silver, followed by inserting lint or prepared 
sponge between the edge of the nail and the skin, kept in place by a band of 
adhesive plaster. This treatment can be repeated every two or three days, as 
required. Uncomplicated with ingrowing nail and cases tending to chronicity 
oleate of tin, ten grains to the ounce of cold cream, salicylic acid, thirty grains 
to the ounce of lanolin ointment, well rubbed into and about the nail, may be 
beneficial. Avoidance of water is frequently imperative in these conditions, 
and under no circumstances should the use of rubber or leather cots or gloves 
be advised, since the nail substance may be destroyed by their use. 

Eemedies indicated by any general departure from health, or local condi- 
tions, should be given. See Graphites, Hypericum and Sulphur. 

Pterygium (Overgrowth of Nail fold) is the abnormal downward growth 
of the fold of skin that covers the proximal end of the nail, hiding the lunula. 
Its treatment consists in freeing it from the nail, and pushing it back or clip- 
ping it off. Osmium is a possible internal remedy. 

ONYCHOMYCOSIS 

(Fungus growth in the nail.) 

Onychomycosis is a morbid process in the nails due to the growth of a 
vegetable parasite in the nail substance. 

Etiology. — Usually occurring by direct spread from affected skin in the 
neighborhood, or more rarely by auto-infection from any part of the body 



116 ATROPHIA UNGUIS 

accessible to the fingers, a positive case of primary onychomycosis cannot be 
proved. Even when no trace of the mycosis can be found elsewhere it is 
impossible to be sure that it has not existed and disappeared before the change 
in the nail attracted attention. Only two known fungi have been discovered 
in the nail, those of favus and trychophytosis; more frequently the latter, 
though it is rarely found in the toe-nails. The clinical pictures are similar, 
the microscope being necessary for differential diagnosis. 

Symptoms. — Soon after the invasion by the parasite, the nail becomes 
brittle and frayed out, its surface furrowed, its substance opaque and yellowish 
or grayish-white, while it is lifted up in bulk by an accumulation of epidermis 
beneath it. In succession the other evidences of hypertrophy appear, the nail 
becomes thickened, distorted, gryphotic, its surface exfoliated and of a pale 
dirty yellow color. In rare cases due to favus there are seen the sulphur- 
yellow or scutate depressions peculiar to that disease. 

^Diagnosis. — Great caution is necessary in the diagnosis of parasitic disease 
of the nails, for the clinical symptoms resemble very closely several other affec- 
tions, particularly psoriasis, chronic eczema, etc. The discovery of the fungus 
with the microscope is the only certain test. Barely more than one or several 
nails are affected by parasitic invasion, whereas in the other diseases mentioned, 
all of the finger, and even the toe-nails may be involved. But failure to find 
the fungus does not exclude its existence, while the presence of fungoid lesions 
on other parts of the body strongly indicates the nature of the disease of the 
nail. Sabouraud claims that the only variety of the trichophyton fungus found 
in the nails is the ectothrix. Either this or the favus fungus can usually 
be readily demonstrated by subjecting scrapings from the affected nail to liquor 
potassse, where, after softening, the parasite can be seen with a microscopic 
power of 400 to 500 diameters. 

The treatment is the same as for the like parasitic affections of the skin 
combined with mechanical removal by scraping or cutting of accessible portions 
of the affected nail. The Rontgen rays have been of service in the treatment 
of obstinate cases of parasitic nail disease. 



ATROPHIA UNGUIS 

Atrophy of the nails (onychatrophia) may be congenital or acquired. If 
the former, it is usually found upon fingers or toes congenitally deformed, and 
is associated with defective growth of hair. Anonychia, absence of the nail, 
sometimes occurs in similar cases. When the digits are distorted or coalesced 
the nails are apt to be malformed as well. Acquired atrophy, more common, 
may affect all or a part of the nail, and results from local or constitutional 
causes. 

Etiology. — Traumatism in the toes from ill-fitting shoes, and in the fin- 
gers from hard manual labor as well as accidental blows or pinches, may 
produce atrophy instead of hypertrophy. It depends upon whether the vio- 



ATROPHIA UNGUIS 117 

lence hinders the activity of the matrix by removing the nail wholly or par- 
tially from it, or enhances it by causing congestion. Extreme heat or cold, 
and constant handling of the chemicals, have an injurious effect upon the 
growth of the nails. Inflammation or ulceration of the matrix will stop 
permanently or temporarily nail formation. All prolonged fevers and chronic 
wasting diseases of the entire system, such as typhoid fever and tuberculosis, 
are constitutional causes of atrophia unguis, acting by disturbing nutrition. 
Others are nervous affections, such as ataxia, and cutaneous diseases, like ich- 
thyosis, which may be followed by either atrophy or hypertrophy. 

Symptoms. — The atrophic nail in appearance is grayish-white and lustre- 
less, either uniformly or in stripes or specks. It is smaller and thinner than 
normal, and its substance is soft and delicate like a thickened membrane. It 
is often rough and irregular from longitudinal exfoliation or fractures or else 
granular erosion gives it a "worm-eaten" appearance. 

Atrophy of the nail may show in some manner distinct enough to be 
entitled to a special designation : 

Spoon nails is the descriptive title given by Crocker to a condition of 
the nails found associated with wasting diseases though also in some cases 
from an undiscoverable cause. The substance is thinned and the surface con- 
cave from side to side. Everted edges and an occasional antero-posterior 
concavity, complete the resemblance to the bowl of a spoon. The disease 
spreads gradually from one nail to others on the fingers, but is never found 
on the toes. 

Reedy nails describes the striated appearance due to the prominence of 
the normal longitudinal marking, occurring upon atrophy or wasting of the 
intermediate substance. Though attributed by Fothergill to gout, it has been 
so often observed in aged persons with no other symptoms of gout that Crocker 
regards it as a change of senility. 

White Nails or Leucopathia Unguium is the frequently observed condi- 
tion of the presence, in nails otherwise healthy, of spots or transverse bands 
of a dead white color. The macules or bands are observed to appear at the 
lunula and grow forward until finally cut off. They generally point to some 
local or constitutional condition which temporarily operated adversely upon 
the formation of the nails. They are sometimes noticed during convalescence 
from fever, or in paralysis. Some attribute the appearance to the presence of 
air in the nail substance. Others believe that it is a trophoneurosis causing 
nutrition changes in the nail matrix. 

Diagnosis of atrophic changes in the nail is easily made by the appear- 
ance found, but it is not so easy to ascertain the true nature (origin) of the 
disease unless some evidences of a related disease, diathesis, etc., is found 
elsewhere. 

Treatment should be adapted to the causal disease and the improvement 
of local and general nutrition. Among remedies acting upon the nail struc- 
tures see Helleb. nig., Hypericum, Kali sulph., Mer. viv., Silicea. Spigelia and 
Thuja. 



11« ONYCHIA 



ONYCHIA 

{Inflammation involving the nail.) 

Onychia or onychitis is either acute or chronic inflammation of the 
matrix of the nail. Its most important forms are the syphilitic, malignant 
and formalin types. Occasionally it is idiopathic. 

Syphilitic onychia, may involve several, but usually only one nail. Gumma- 
tous infiltration of the peripheral soft parts, or development of the bullous 
syphiloderm beneath or near the nail, threaten seriously its integrity, and lead 
to ulceration with a foul discharge. 

Onychia maligna usually results from a traumatism in a patient of the 
strumous diathesis or with some grave chronic disease. Beginning as a 
simple inflammation it soon becomes phlegmonous. The nail is lifted from its 
bed—by the exudation underneath of a sero-sanguineous fluid. The nail be- 
comes thickened (onychauxis), opaque and discolored, and is often separated 
when gangrenous; an easily bleeding surface is uncovered, which may slowly 
heal and produce an imperfect nail; or the inflammation may extend to the 
neighboring parts, producing true paronychia with often involvement of the 
bone. Sometimes the condition becomes chronic. 

As the direct result of increasing use of formalin in science and the arts, 
a particular form of onychia {formalin onychia) associated with a dermatitis 
must be noted. These cases result from the continued use of 4 to 10 per cent, 
solutions of formalin, and are most obstinate in their response to treatment. 

The diagnosis may be established by the signs of the primary disease 
which predisposed to it, or history of injury and evidences of inflammation 
or its resultant effects. 

In the treatment of severe onychitis incisions or removal of the nail may 
be necessary to relieve tension, maintain cleanliness and permit the direct 
application of an antiseptic dressing. A twenty-five to fifty per cent, icltthyol 
ointment or one composed of two to ten per cent, of salicylic acid may be used 
for continuous application. Internal remedies indicated for the original dis- 
order, or for the local conditions when idiopathic, should be chosen. Besides 
remedies adapted to syphilitic cases, see Cocculus, Fluor, acid, Graph.. Hepar 
sulph., Kali mur., Lycopod.. Nat. miir.. X. sulph.. Phos. acid. Sarsaparilla, 
Silicea and Sulphur. 



LENTIGO 119 



CLASS II.— IDIOPATHIC AFFECTIONS 
LENTIGO 

(Freckles; Ephelides.) 

Definition. — Multiple circumscribed macular pigmentation of the skin, 
commonly occurring in pin-head to pea-sized spots on the face and hands. 

SYMPTOMS. — Freckles may be rarely congenital, but are nearly always 
acquired in the second decade of life, and appear as yellowish-brown or blackish 
spots in few or large number. They are most often limited to the parts of 
the skin exposed to sunlight, as the face, neck, back of hands and forearms ; 
about the face they are apt to be more numerous on the temples and cheeks. 
Less frequently freckles appear on the arms, back, buttocks and genital 
regions of both sexes. They generally make their first appearance in summer, 
suddenly or slowly, while with the onset of winter they fade partially or wholly 
away, to become more conspicuous again with the return of warm weather. 
Pigmentations of this nature which are uninfluenced by seasons, whether lim- 
ited to the exposed or on the covered parts as well, are known as "cold freckles." 
Usually freckles are symmetrically distributed, very rarely they may be asym- 
metrical; occasionally they are symptomatic, and may develop progressively 
into large plaques without losing their pathological character. Lentigo-like 
pigmentation may be secondary to other changes in the skin, as in the atrophic 
form of xeroderma pigmentosum, in the cutaneous atrophy of old age. and in 
senile eczema. 

Etiology and Pathology. — Exposures to the direct solar rays of heat 
and light or to warm moist conditions of air are the ordinary causes of lentigo. 
Light complexioned people, especially those with red hair, are most subject 
to freckles, but they are not unusual in brunettes or even in the colored races. 
Symptomatic forms may be caused by conditions leading to errors of nutrition. 
Freckles are due to an excessive deposit of pigment in circumscribed areas of 
the mucous layer of the epidermis, not extending into the corium as in pig- 
mentary nevi. 

Diagnosis.. — The distinguishing points of ordinary freckles are their loca- 
tion on the exposed surfaces of the skin, their aggravation in summer and 
amelioration in winter, and occurrence in multiple, circumscribed spots, first 
appearing between the eighth and twentieth year. 

For treatment see chloasma. 



120 CHLOASMA 

CHLOASMA 

(Liver spots; Moth patches.) 

Definition. — A single or multiple, circumscribed or diffuse staining of 
the skin, of a yellowish-brown or blackish color. 

Symptoms. — Circumscribed patches of chloasma are usually well defined 
and vary in shape and size ; the diffused patches are less sharply defined ; both 
forms are commonly yellowish-brown in tint, but may be of a dark brown or 
black, known as melanoderma. In the generalized form, the relatively deeper 
colored parts of the skin, as the axillae, genitals, nipples, etc., seem most affected. 
There are no subjective sensations. 

Etiology and Pathology. — The pathogenesis of chloasma varies in its 
inception. In the idiopathic form numerous sources of local irritation or in- 
flammation may cause it, chloasma traumaticum. Thus it may follow artifi- 
ciaPvesicants, or rubifacients, such as mustard and other forms of poultice 
applications (chloasma toxicum). Long-continued pressure upon the skin, 
or repeated frictions may lead to pigmentation. Excoriation from scratching 
in pruritic and parasitic skin diseases or conditions of long standing at all 
ages may frequently cause pigmentary deposits, pityriasis nigra. Similar dis- 
colorations of the surface of persons subject to irritations and scratching from 
uncleanliness, known as "vagabond's disease," are observed in tramps, paupers, 
persons of unsound mind, etc. Exposures to unusual, repeated or prolonged 
heat or cold may result in staining, chloasma caloricum. This is seen on the 
legs of stokers, the face and neck of firemen, foundrymen, etc. In this group, 
pigmentation from the erythema, produced by the X-rays, should be men- 
tioned. Even the covered parts may participate in the deeper color-pigmenta- 
tion, and it is said the vigorous are most liable to experience these effects. 
Severe cold may produce a secondary local hyperemia of a nature to cause 
deposits of coloring matter from the blood. 

Symptomatic chloasma may follow certain skin affections independent of 
pruritus, or from pathological changes of the internal organs, tissues or fluids 
of the body. Pigmentations are incident to the skin lesions of syphilis, leprosy 
and lichen planus, and are often of long duration. They may follow exudative 
erythemas, acne, etc. ; then they may be marked, but are usually not persistent. 
In dependent locations, as between the knee and ankle, almost any congestion 
or inflammation may cause staining of the surface. Here the influence of grav- 
ity tells upon the otherwise disabled blood-vessels. Less constant and marked 
are the concomitant colorations sometimes observed in senile atrophv of the 
skin, in fibroma, about patches of leucoderma. and rarely in psoriasis and 
pityriasis rubra. 

Excessive pigmentation of the skin may be a symptom of diseases of the 
spleen, liver, suprarenal capsules, cancer, changes in the blood, thus producing 
cachectic states. Of these cachectic chloasmas, examples of a general bronzing 
of the skin are seen in Addison's disease, and the peculiar sallowness in cancer ; 





Fig. 37— CHLOASMA 

(front view.) 




Fig. 38.— CHLOASMA 
(Melanoderma.) 

(rear view.) 

Patient, a male baby of eight months. At birth a solid dark brown patch 
covered the lumbar and sacral regions and both nates; also, a number of small 
areas of pigmentation were present on the back, head and extremities. These small 
spots increased in size and others appeared during the first three months of life, but 
have remained stationary since. General health of the baby is good, and both 
parents, who are of German origin, are robust. Sepia, sixth decimal, failed to 
influence the pigmentations. 




Fig. 39.— CHLOASMA 



Patient, a maiden lady of thirty-nine. Duration of disease, four years. A 
faint yellow pigmentation first appeared on the knuckles of both hands. When the 
case was seen there was a generalized light brown pigmentation on hands, arms, 
face, neck and thighs. Uterine disorders appeared as the causal factors. Cured by 
the internal use of dmicifuga, third decimal, and the external application of peroxide 
of hydrogen (full strength) continued for nearly a year. 



CHLOASMA l^ 1 

diffused or circumscribed patches on the face or body in marked or prolonged 
cases of malaria, Graves's disease, abdominal tuberculosis, and sometimes in 
the advanced stage of hepatic cirrhosis. 

Chloasma uterinum is a term used to designate staining of the skin, due 
to some known or supposed affection of the womb or its appendages. It is 
seen in women between puberty and the menopause, most often during preg- 
nancy (chloasma gravidarum), after multiple pregnancies, in the sterile, or in 
single women in middle life. It is more common on the forehead and tem- 
ples, and it may form a symmetrical mask-like shape over the face, or appear 
in smaller freckle-like irregular spots here and there. It is not uncommon 
on the neck, the nipples and over the central line of the abdomen, while it 
may appear on any part of the body. The shade of coloration is frequently 
like the stains of jaundice, hence the term "liver spots" ; the hue may be a 
rusty or even a blackish-brown in exceptional cases. Sometimes the color will 
vary in the same person under different external or internal influences. 
Chronic constipation alone or associated with other disturbances of excretion 
is sometimes a factor in the production of chloasma. The author has seen 
two cases in which no other cause was apparent. 

Pigmentations which are congenital are usually secondary to interuterine 
conditions, or possibly are caused by pre-natal influences. The editor has seen 
five cases of extensive pigmentation which were congenital, one involving the 
entire right side of the body, excluding the head, and another forming a wide 
band about the waist, posteriorly, but not anteriorly. Both of these gave 
undoubted histories of pre-natal influences, but because of the poor prognosis, 
it was impossible to keep them under observation. 

Pathology. — The origin of pigment in the skin is still unknown, since 
it cannot be determined whether migratory pigment-carrying cells cause the 
pigmentation of the skin, or whether the pigment granules themselves migrate. 
However, the direct cause is an excess of pigment deposit (melanin or hemosid- 
erin), in the rete mucosum, and in the cases symptomatic of some grave disease 
the deposit may penetrate into the upper layers of the corium. Sometimes the 
papillary vessels have been found dilated, and about the latter wandering cells 
overloaded with pigment. Excessive blood supply in the skin, excess of pigment 
production, distant or local, or sympathetic nerve influence, one or more would 
seem to be essential to the pathology of chloasma. 

Diagnosis. — Chloasma is recognized with ease as a rule : From erythemas 
of congestion or inflammation, by the reddish color of the latter and their 
disappearance on pressure ; from fungus discolorations of the skin, as in tinea 
versicolor and erythrasma, which may be very like in hue, by the usual differ- 
ence of location, signs of fine desquamation, by microscopic evidence of the 
presence of the characteristic fungi, and, in case of doubt, by the nearly im- 
mediate effects of suitable antiparasitic treatment on the latter diseases. Ac- 
cidental or voluntary stains of the skin and the discolorations of chromidrosis, 
if suspected, can easily be removed by washing with soap and water or some 
suitable chemical. A patch of leucoderma with apparent increase of pigment 



122 CHLOASMA 

at the border may be known by the total or partial absence of normal pigment 
on some portion of the patch. 

Prognosis. — Generally this must be guarded, though there is always hope 
of relief in cases in which the cause is known and can be removed. When 
secondary to other lesions of the skin recovery may be nearly always expected. 

Treatment. — Causal treatment should always be instituted when pos- 
sible, to remove or neutralize causes yet present, or to antidote antecedent 
factors. To this end it may be necessary to review the whole etiological field. 
The ordinary causes of lentigo are well known but difficult to avoid; some- 
thing can be done for women in this direction by protection of the exposed 
part ; men do not apply for treatment. Constipation should receive attention 
by physiological methods and indicated drugs. Affections of the liver, uterus 
and appendages, other local internal diseases and constitutional states may de- 
mand treatment which cannot be detailed here, more than to give a few indi- 
cations for remedies on a later page. Though a dermatologist is sought usually 
to give relief for the cosmetic blemish, he can only do this in many cases by 
attention to the whole pathogenesis, whether local or constitutional. It is not 
difficult to remove the epidermis and with it the pigment deposit, but with- 
out an elimination first of the influence which provoked the abnormal de- 
posit it is likely to return. Even under favorable conditions of health local 
treatment is far from satisfactory, and should only be employed after physio- 
logical and internal pathogenetic means have failed. 

A host of external applications have been recommended for the removal 
of freckles and chloasmata. Some of the best are as follows : 

1$. Corrosive sublimate gr. 6. 

Distilled water § 6. 

Spirits camphor, 

Rose water aa 5 J. M. 

This may be applied to the pigmented skin two to four times a day, or if a 
more decided effect is needed, three folds of linen cloth, cut to fit the lesions, 
may be wet with it, applied at night andallowed to remain until dry. Which- 
ever way employed, when the skin becomes red and begins to flake off, the 
sublimate solution should be discontinued and a mild salicylic acid ointment 
used to promote exfoliation as long as needed. 

1$. Salicylic acid gr. 25. 

Simp, cerate § 1. 

01. amagdal dulc 5 1. 

M. Sig. — Apply externally once or twice daily. 

To hide the redness of the surface during the day, a powder composed of 
equal parts of carbonate of magnesia and talcum can be dusted on the skin, 
if desired. The treatment can be repeated, beginning with the sublimate 
solution when required, or the ointment long continued may be found suffi- 
cient to prevent a return of the pigmentation. The ammoniated mercury may 



CHLOASMA l^ 3 

be employed for limited pigmentation in the combination as given below, ap- 
plied nightly or every other night : 

T$. Hydrarg. ammon., 

Bismuth magister aa 5 1 • 

Adipis recentis S 1. 

M. Sig. — For external use. 

Or, chloride of bismuth may be tried with baryta : 

1$. Bismuthi chlor. precip 3 1. 

Baryt. sulph. precip 3 4. 

Simple cerate, 

Glycerine (pure) aa 3 li- 

M. Sig. — Use externally once daily or less frequently. 

Probably the bichloride of mercury is the most reliable application. In 
obstinate cases it may be used cautiously in stronger solutions than given 
above; in the proportion of two to four grains to the ounce of either cologne, 
tincture of benzoin, tincture of Tolu balsam or dilute alcohol. Peroxide of 
hydrogen may be applied a few times followed by a salicylic acid ointment or 
collodion. Alcohol (95%) and tincture of benzoin, equal parts, applied daily 
until desquamation results, is sometimes effective. All applications for the 
removal of pigment should be used with care, lest they excite too much inflam- 
mation of the skin and defeat the object desired. Electrolysis may be used in 
the removal of small areas of pigmentation. 

For internal medication see indications for Cadmium sulph., Cal. phos., 
Lycop., Phos., Nat. ars., Nit. acid, Sepia and Sulphur. 

There are a number of discolorations of the skin which instead of Deing 
the result of excess deposits of coloring matters normally present in the skin, 
are due to the introduction into the integument of coloring substances from 
other organs, or from without. Thus picric acid, arsenic, toxic gases, chrysa- 
robin, etc., cause temporary staining. The bile in icterus colors the skin 
almost any shade of yellow. 

Argyria is a form of discoloration of the skin from the too free ingestion 
of silver salts internally, or in workers in silver manufactories, from the 
penetration of the epidermis by minute particles of the metal. The mucous 
membranes, as the conjunctiva, gums, etc., may be discolored also. The author 
has a patient who has worked on metallic silver for twenty years and has a 
nearly universal light slate color of the skin. The deposit may not affect the 
general health, and no method of removal is known, although a change of oc- 
cupation will always benefit and may materially aid in relieving the condi- 
tion. Kali iodide in material doses has been reported as curing two cases. 

Tattooing with needles moistened with some indelible colored substance 
and made to penetrate into the corium produces a permanent discoloration. 
This artificial pigmentation is quite often seen on the hands, arms or other 
parts of the skin, of various designs or shapes dictated by fancy, and sometimes 



124 ERYTHEMA— ERYTHEMA SIMPLEX 

considerable in extent. Of like appearance and nature are the stains left by 
grains of gunpowder imbedded in the skin by explosions. 

Treatment of these cases heretofore has been by electrolysis, cutaneous 
trephine and excision and for the most part has been found unsatisfactory; 
more recently tattooing the patches with glycerol of papoid has been reported 
as effective in removing both the stains from pigment tattooing and from gun- 
powder explosions. The use of caroid as a solvent in place of papoid has been 
recommended. Before using either of these preparations the surface should 
be rendered aseptic and surgical cleanliness adhered to throughout. 



ERYTHEMA 

Strictly speaking, this term implies the existence of a hyperaemic redness 
of the^ skin, which may be made to momentarily disappear on pressure (ery- 
thema simplex). Clinically it includes degrees of redness which in some 
part have gone beyond the stage of hypersemia and entered on a stage of in- 
flammation, i.e., exudation. These latter types are included under the 
erythema exudativum, and include erythema multiforme, iris and nodosum. 
There need be no confusion therefore, from the rather wide use of these terms, 
especially in view of the fact that the line between congestion and inflamma- 
tion cannot be a fixed one in a clinical sense. For clinical convenience also, 
some erythemas, having no relationship in pathogenesis, are grouped to- 
gether. 

ERYTHEMA SIMPLEX 

Simple forms of hyperaemic redness of the skin due to vascular dilata- 
tion from some disturbance of the vasomotor nerves, are included under this 
head. They arise from different causes, and may be little more than physio- 
logical, or they may be pronounced and have a resemblance to severer types 
of disease. The areas of redness vary in shape, location and extent with the 
causes which produce them. 

Erythema neonatorum. — The diffused, often universal redness of the 
skin beginning soon after birth is frequently due to friction from washing, 
rubbing, or the clothing of the new born. It reaches its height in about three 
days and disappears by the end of a week. There is no desquamation, but not 
infrequently a change from the red to a yellowish tinge of the skin is seen, 
and occasionally hemorrhagic points appear. 

It may be diagnosed by the occurrence in the first week of life, universal 
distribution and absence of any systemic disturbance. 

ISTo local treatment is needed beyond an avoidance of irritative manipula- 
tions of the skin; and in severe cases, light applications of pure olive oil. 
Copaiva. sixth decimal, internally, will hasten recover}'. 

Erythema intertrigo (Intertrigo; Eczema intertrigo). 






ERYTHEMA SIMPLEX 125 

Symptoms. — As the name indicates, this is an erythema between two op- 
posing or chafing surfaces. It occurs about the buttocks, groins and folds 
of the skin of the neck in infants; in fat adults it may occur about the neck, 
in tlie axilla, groins, and less often on the prepuce in men, the vulva and under 
the breasts in women. The congested surfaces are often moist from the pres- 
ence of a muciform or muco-purulent exudation and the most intense red- 
ness is frequently at the junction of the two folds of skin, due probably to the 
greater imprisonment of sweat and exudation there. The affected skin is 
liable to become eczematous, or a dermatitis may follow on a prolonged or un- 
relieved attack. 

Etiology. — In infants lack of cleanliness and attention to the removal 
of soiled clothing, or some irritating quality of the urine, feces or sweat are 
common causes of intertrigo. In adults, a gouty diathesis, obesity, free per- 
spiration and neglect are probably the usual causes. Heat, friction and moist- 
ure co-operate to make the condition possible. 

Diagnosis. — From eczema by the limits of intertrigo to opposing sur- 
faces of the skin, the deeper redness at the junction of the two surfaces, by 
the discharge not stiffening the linen and by the apparent absence of much 
itching. Seborrhceic dermatitis is no doubt mistaken for intertrigo, but the 
former, if beginning on the skin in contact, is likely to spread on to the free 
surface, is apt to be worse at the periphery of the patch rather than at the 
junction of the skin with itself, and greasy scales at some point can be usually 
found. So-called intertrigo of the genitals is nearly always seborrhceic in 
origin. Congenital syphilis in infants may give rise to more or less erythema 
of the buttocks, but the redness is not limited to that region, and other signs 
of syphilis usually appear. Tinea circinata or eczema marginatum, as it was 
named by Hebra, when occurring on the inner aspect of the thighs, can be 
recognized by the characteristic "festooning" of the elevated border, by its 
exudative type, and by the microscopic evidences of a fungus. 

Treatment. — Removal of the cause, cleanliness, mechanical agents to pro- 
tect the surfaces in contact, and the indicated remedy comprise the methods 
of relief. After the surfaces are cleansed, they may be dusted over with some 
simple hygroscopic powder, such as finely-powdered starch, rice, lycopodium, 
etc., and if the surfaces are not subject to much friction a fold of sheet lint 
can be laid over the powdered surface. In intertrigo of the axilla and under 
the dependent breasts of women the powder bags recommended by Unna are 
a useful device. The bags are filled with a fine powder and then stitched 
(quilted) across to prevent shifting of the powder; worn under the breasts 
or armpits, they not only absorb the discharges, but by even pressure diminish 
the flow of blood into the weakened capillaries. On surfaces subject to con- 
siderable friction a lubricant may be of more service than a powder; this may 
consist of vaseline, cold cream salve, or any non-irritating sterilized oil or fat. 
In the most severe types the editor uses carron oil freely spread upon fine 
linen, in preference to all other local treatment. If a medicated ointment 
is needed, five to twenty grains of gallanol or the same of boric acid may be 



126 ERYTHEMA SIMPLEX 

thoroughly incorporated in an ounce of benzoated lard or vaseline for the 
purpose. Both substances possess the advantage of a local action only. Gouty 
subjects must be dieted if a rapid recurrence is to be avoided. Tor internal 
use see indications for Benzoic acid, Hypericum, Lycop., Merc, viv., Nat. 
phos., Nit. acid and Sulphur. 

Erythema traumaticum. — Local redness of the skin resulting from 
friction, pressure or injury; if moderate and temporary, may be of slight im- 
portance and generally subsides on removal of the cause. If intense or con- 
tinued, it may pass into inflammation in the form of dermatitis, or papular, 
vesicular or pustular eruptions common to other diseases may follow, and 
even result in local gangrene or ulceration. 

'Erythema paratrimma is a name formerly used to denote the redness 
from pressure over a prominence, threatening the formation of a bed sore. 
Happily the latter is no longer a common sequence. Some ordinary causes 
are the pressure from garters, clothing about the waist, tight or ill-fitting 
'shoes, from occupations requiring long sitting; from the contact of irritat- 
ing secretions from the mucous outlets, or other discharges, as in some 
cases of intertrigo, when practically the latter is identified with traumatic- 
erythema. 

The treatment is chiefly causal. Other measures can be employed as 
indicated for intertrigo, if required. Sometimes pigmentation may remain 
as a result of continued or repeated local erythema. The more severe cases 
may require Arnica, Borax, Graph, or Hypericum internally. 

Erythema caloricum. — Hyperaemic redness of the skin resulting from 
exposure to either heat or cold is not uncommon. The so-called "sun burn" 
is perhaps the most familiar example of this form of erythema. It may re- 
sult from atmospheric cold as well, which, if long enough continued, may 
produce a bluish or livid color from venous stasis. From artificial heat it is 
seen in cooks, stokers and others who are in the habit of warming their legs 
by the fire; this erythema ab igne of Crocker shows in rings and gyrate shapes 
on the front of the legs, which gradually become darker from pigmentation. 
If the exposure to heat is discontinued the redness gradually disappears, leaving 
a brownish discoloration, which is said to have been mistaken for syphilitic 
stains. All forms of erythema caloricum of much duration are likely to induce 
pigmentation, which slowly disappears after the cause is avoided. This variety 
of erythema easily develops into dermatitis calorica if the heat or cold is in- 
tense enough or long continued. 

The diagnosis of erythema calorica is easily made and is sometimes of 
importance in the way of excluding other forms of redness or pigmenta- 
tion. 

No treatment is required beyond avoiding the cause and the simplest 
means for temporary protection of the reddened skin. Barely there may be 
a persistency of the erythema calling for internal medication. The writer has 
reported one marked instance of this kind of six months* duration, due to 
cold, and which was rapidly cured with Belladonna. Other remedies likely to 




Fig. 40.— ERYTHEMA SCARLATINIFORME 

STAGE OF DESQUAMATION ON' THE FACE THIRD DAY AFTER ONSET. ERTTHEMA STILL 

PRESENT ON THE TRUNK 

The subject, a vigorous man of thirty-two, who habitually drank freely of beer. 
Symptoms began with moderate febiile disturbance, headache and loss of appetite; 
on second day intense scarlet redness of face, with puffiness of eyelids; redness ex- 
tending to trunk on third day; slight sensations of heat and burning. Cured with 
chininum sulph., third decimal. No local treatment. 



ERYTHEMA SIMPLEX 1^" 

be indicated are Agaricus, Arnica, Borax, Cad., Canth., Carbo am., Crotal., 
Hcpar, Nit. acid, Rhus. tox. and Sulphur. 

Erythema pudoris et iracundiae is a name given to a usually physiological 
flushing of the skin of the face, neck or upper part of the body, generally as 
a reflex effect of emotions, but sometimes from severe mental or physical ex- 
ertion. It is nearly always transient in duration. When it becomes persistent 
or in any case causes mental distress, mortification, depression, etc., it is essen- 
tially pathological, and as such demands medical treatment by indicated 
remedies, chief of which are Bell, and Nux Vomica. 

Erythema laeve denotes a redness of the skin of the extremities consecu- 
tive with swelling, cedema and tension of the part, and due to vascular 
weakness. If long-continued, eczema or other form of inflammation is likely 
to develop. 

Erythema medicamentosum or congestion of the skin due to the ingestion 
of drugs, will be considered under dermatitis medicamentosa. 

Erythema venenatum will be described under dermatitis venenata. 

Erythema gangrenosum will be found under dermatitis gangrenosa. 

Erythema pernio, or chilblain, will be treated under dermatitis calorica. 

Erythema vacciniforme is included in vaccination eruptions. 

Erythema scarlatiniforme (Erythema roseola, etc.). — Under the above 
captions and other divisional heads are included non-contagious exanthems 
frequently closely resembling the rash of scarlet fever, less often rubeoloid in 
appearance, and in the mildest degree, especially in infants, presenting a 
roseola-like redness. Distinctions in name have been made between those 
cases unattended with pyretic disturbance and those exhibiting some rise in 
systemic temperature ; and of the latter between the desquamative and the non- 
desquamative. These distinctions have been elaborated particularly by French 
dermatologists, and are not fully admitted by observers in other countries. 
Space does not permit a discussion of the merits of these subdivisions here. 
After an observation of all grades of scarlatinoid erythemas during thirty- 
five years of general and consultation practice, the author can see no good 
grounds (etiological or otherwise) for dividing these cases, except in the 
matter of degree. While they certainly may be due to widely different causes, 
it is not apparent that any one or class of causes produce a distinct type of 
erythema, or, in fact, that they necessarily always produce any ery- 
thema at all ; and it is likely that individual peculiarities have quite as 
much to do with the degree of eruption and general disturbances as have the 
different causal factors. In general it may be said that the milder cases exhibit 
most often roseola forms of hypersemia, and the severer cases the rubeoloid 
or scarlatinoid forms. In pathogenesis this class of erythemas may be idio- 
pathic or symptomatic. 

In the mildest form, the erythema may occur quite • suddenly in small 
macules or in a punctate rash, distributed over the face, trunk and extremities. 
It is chiefly seen in infants or young children, erythema infantilis, and lasts 
only a few hours, erythema fugax. or a few days, disappearing without 



128 ERYTHEMA SIMPLEX 

desquamation. In form or color there may be a likeness to roseola, measles 
or scarlatina, but no other symptoms of the two last diseases appear. The 
term erythema roseola is a superfluity of expression which had best be dis- 
carded altogether as a name. It refers, of course, to the roseola form of ery- 
thema and is, therefore, a roseoloid rash which it is absurd to dignify by title 
as distinct from a rubeoloid rash due to the same causes and of the same 
nature. 

In a second degree, there may be a temporary rise of temperature of one 
to four degrees preceding the appearance of the eruption. A coated tongue, 
restlessness and occasionally a moderate redness of the fauces and palate may 
attend the fever. The erythema commonly occurs in moderate-sized macules, 
without any rule as to shape or distribution. Sometimes there are rings of 
redness or figurate shapes; at other times the erythema may be punctate or 
diffused more or less widely, rarely being universal. The redness is of short 
duration, but may reappear at new points and so continue for several days. 

In other cases, with even less constitutional disturbance (which soon sub- 
sides), the rash may appear quite suddenly in the form of a punctate ery- 
thema almost exactly like the efflorescence of scarlet fever, but without any 
regularity as to location. The face frequently is not involved, and if so, 
the redness is apt to be sharply defined, as it may be also elsewhere. The 
eruption may lose its punctate character and a diffused redness remain for 
from three days to a week from the beginning, followed generally by a fine or 
flaky desquamation, according to the intensity and duration of the eruption. 
The fauces show some degree of redness. Like the mildest form of erythema, 
these eruptions are chiefly seen in young children, but are not uncommon in 
older children or rare in adults. 

Very similar forms of erythema may occur as an occasional symptom dur- 
ing the onset or career of a large number of diseases, some of them charac- 
terized by other lesions and many of them febrile in nature. Patchy erythema 
may attend the onset of variola, varicella, vaccinia; occur in the course of 
diphtheria, malaria (roseola febrilis), influenza, etc. Occasionally rubeoloid 
or scarlatinoid eruptions are seen with these and other diseases. Frequently 
during the onset of syphilis finger-end-sized spots of faintly or dull red ery- 
thema may be observed. 

The most severe degree of diffused erythema has been described by French 
'authorities as erythema scarlatiniforme desquamaticum, in which the mucous 
surfaces are often affected to a considerable extent, so that the tongue be- 
comes somewhat denuded and looks smooth or raw; there is more or less 
sore throat, and sometimes the nasal membrane and the conjunctiva are 
affected. The eruption may be punctate, but it is more often a diffused red- 
ness, and more persistent than in other forms. Desquamation in large scales 
begins during the first week, the flakes gradually becoming smaller until they 
cease to form. Scaling on parts of the skin not at the seat of the eruption may 
occur, and in severe cases the nails and hair may fall out. The whole dura- 
tion of an attack is seldom less than three weeks, and may be prolonged to 



ERYTHEMA SIMPLEX 129 

two months. There is a marked tendency to recurrence of the attacks, espe- 
cially with the change of the seasons, and in cases due to uremia or some 
diathesis. Among the relapsing desquamative erythemas, it is well to note 
that rare congenital form called '"deciduous skin" or keratolysis, in which the 
person afflicted periodically casts off a portion, of varying extent, of the der- 
mal covering. 

Erythema scarlatinii'orme in any degree may give rise to subjective sensa- 
tions of pricking, burning or itching; these may be pronounced and trouble- 
some, or trivial, transient, and in many cases altogether absent. Occasionally 
with the erythema, miliaria vesicles may be found, some swelling of the skin 
exist, or hemorrhagic points appear. It will be understood, of course, that 
when erythema is symptomatic of some distinct disease or condition, the symp- 
toms, both subjective and objective, of the primary affection may be present. 

Etiology and Pathology of Ehythema Simplex. — Idiosyncrasy un- 
doubtedly plays a prominent part in the operation of the causes which produce 
the forms of erythema under consideration. Age is a predisposing influence, 
as the affection is much more common in children than in adults. In the 
early years of life gastro-intestinal disturbances are apparent causes of the 
milder forms of erythema. Change of season without any corresponding 
change in diet, especially in the over-fed, may lead to an outbreak. Certain 
foods, either fruit, vegetable, shell-fish or meat, may cause it. Habitual ex- 
cess of hydro-carbon elements in the food I have noted in the history of some 
cases, and the existence of fermentative indigestion in a few others. Sewer 
gas poisoning and auto-intoxication with ptomaines have been named as 
causes, also excess of certain elements in the fluids and tissues of the body, 
such as produce rheumatism or gout. Injuries to the surface abundantly sup- 
plied with nerves, or surgical operations, may reflexly cause an erythema. 
Before the days of antisepsis, septicaemia, pyaemia and puerperal affections 
were responsible for some cases; even now imprisoned pathological secretions, 
as from peritonitis, empyema, etc., may be causal factors. Uraemia, malaria 
and several eruptive diseases have been referred to as causes in a previous sec- 
tion. Some exceptional peculiarity in the primary disease or in the individual 
attacked is the only explanation known for the occasional resulting erythema. 
The latter supposition applies also to the exceptional effect of drugs upon the 
skin, which may show any of the forms of erythema described, as well as other 
types of eruption. Some of these drug effects may come from their elimina- 
tion by the skin, but most are in the nature of a reflex from irritations of nerve 
tissues within the body. They are discussed under dermatitis medicamentosa. 
In a large proportion of cases of erythema no cause is apparent. 

Eegarding the pathology of scarlatiniform erythema little can be added 
to what has been said under etiology. The most probable theory is that certain 
individuals possess an inherent intolerance of the nerve centres to the pres- 
ence of some substance temporarily circulating in the system, producing re- 
flexly a dilatation of the cutaneous blood-vessels. The degree of intolerance 
may have as much to do with the degree of the erythema as has the nature or 



130 ERYTHEMA EXUDATIVUM 

quality of the toxic substance, whether the latter be physiological (to most 
persons), pathological or medicinal. Brocq advances the opinion that the 
desquamative form of erythema scarlatiniforme is a mild variety of pityriasis 
rubra. Judging by the cases occurring in this country there is no basis for 
that belief, though the severe desquamative forms are here comparatively rare. 
In a large ambulant clinic and in five hospitals the author has seen only one 
marked case in several years. 

Diagnosis. — Eecognition of erythema scarlatiniforme is important, but 
not always easy and sometimes very difficult. The many instances of recur- 
rent scarlet fever in former days were doubtless many of them types of scar- 
latiniform erythema. A comparison of the most common symptoms of the 
two affections will usually determine the diagnosis. Thus while the throat 
may be red in erythema, it is not swollen as in scarlatina; the strawberry 
tongue of the latter is absent; the rise of temperature may be considerable, 
but is not continuous as in scarlet fever; the erythema patches are apt to be 
welTdefined with areas of clear skin between in contrast with the less red and 
diffused scarlatina eruption; nephritis is not associated with erythema except 
as a cause; the latter is non-contagious and desquamation begins early, on 
the third or fourth day; scarlatina is contagious, and desquamation does not 
begin until the ninth or tenth day. The latter difference will generally clear 
up doubtful cases. Isolation is the only safe course in the interval. "When 
an erythema resembles the efflorescence of measles, there would not be a 
history of a prodromal coryza and fever with continued rise of temperature 
after the outbreak of the eruption as characterizes the latter, neither would 
the rash of erythema be likely to begin upon the face. If rotheln is suspected 
from the appearance of the erythematous rash, and there is no enlargement 
of the submaxillary, sterno-mastoid or occipital glands found, it may be 
excluded, unless there is a clear history of contagion. 

Prognosis. — This is nearly always favorable, the exceptions being some- 
times in cases resulting from such grave, conditions as pyaemia, septicaemia, 
uraemia, etc. If the attacks of erythema are due to an idiosyncrasy, they are 
very likely to recur sooner or later from the same or other causes. 

Treatment. — No local treatment is needed beyond mild ammonia or soda 
baths. If desquamation is a feature, it may be facilitated by applications of 
non-medicated oil or fat. The appropriate internal remedy will modify the 
course of scarlatiniform erythema and tend to prevent a recurrence. See 
indications for Ailanth., Am. carb., Bell., Chin, sulph., Colcli., Hyoscy., Jug- 
lans tin., Stramon. and Terebinth. 



ERYTHEMA EXUDATIVUM 

Erythema multiforme is a congestive disease of the skin attended with 
various degrees of exudation, as exhibited in elevated lesions, diverse in size, 
shape and color. The different aspects of the eruption have led to the use of 
several names to distinguish the most prominent objective features present 
at the time. These terms will be found further on in the text. 




Fig. 41— ERYTHEMAIMULTIFORME 

ACUTE ERYTHEMATOUS VARIETY, BILATERAL OF TRUNK 

Patient, man aged forty, of sedentary habits; a hearty eater, but in good general health. 
Disease began four days ago with chilliness, headache, lassitude; followed by fever, aching 
and sore throat on second day, with added perspiration on the third. Then maculo- 
papular spots, pinhead to pea sized, appeared, rapidly increasing in area, some coalescing 
in map-like shapes. The symptoms indicating anlipyrine, it was prescribed in the third 
decimal and effected a rapid cure with the aid alone of dietetical measures. 




Fig. 42.— ERYTHEMA MULTIFORME 



ACUTE, PAPULOVESICULAR AND CIRCIXATE VARIETIES 

Patient, a young girl who is occasionally exposed to wet and cold. Eruption 
began a few hours after getting wet, in the form of papules which spread at the 
periphery and became vesicular at the center except three; these cleared centrally 
to become circinate. One lesion had a vesicular border, and the largest a single 
vesicle on one side. The central vesicles dried within a day into darkish crusts. 
Duration, five days. Sensations of burning, stinging and aching were worse when 
quiet, at night, and better from firm pressure. Cured with rhus tox., sixth decimal 
alone. 



ERYTHEMA EXUDATIVUM 181 

Symptoms. — Multiform erythema shows a marked preference for certain 
locations. These in the order of frequency are on the back of the hands ; the 
forearms, the dorsum of the feet, the legs, face, neck and back; occasionally 
the eruption is seen on other parts of the surface ; rarely it is generalized over 
the whole skin and may come on the mucous surfaces of the mouth, tongue 
and eyes. Very often slight systemic disturbance precedes and attends the 
eruption, such as dull pains in the head, back, legs, or only in the joints, with 
a general sense of illness. ' A few cases may have more severe symptoms with 
considerable fever (from 101° to 105°) and an accelerated pulse. Swelling 
of the spleen has been observed. In from one-half to three or four days the 
eruption appears on the surface, nearly always first upon the backs of the 
hands, later involving some other portions of the surfaces above named; but 
occasionally not extending beyond the dorsal surfaces of the hands and fore- 
arms. The distribution is commonly bilateral but not fully symmetrical, per- 
haps showing earlier on one side than on the other. The temperature may 
subside with the first outbreak of the eruption, or it may continue as long 
as the latter extends, or even rise during that period. Occurring in children 
the disease is likely to be attended with more febrile and other systemic symp- 
toms than in adults. The primary lesions may occur in the form of convex 
papules, of a bright or purplish-red color, varying in size from a pin-head to 
a pea, and grouped discretely or close together in patches, erythema papulatum. 
The papules may coalesce if near together or increase in size by peripheral 
extension until a deep red, blotched, irregular patch is formed, from which 
the color can be made to nearly or quite disappear by moderate pressure. Often 
the eruption is of short duration, fading away, sometimes with slight des- 
quamation, and leaving a temporary pigmentation. Occasionally the dis- 
crete papules may increase to the size of a nodule or tubercle, erythema tuber- 
culatum or tuberosum. Papules or tubercles continuing to enlarge may re- 
solve in the centre, forming a slightly elevated ring of redness in contrast 
with the depressed pale or purplish-red centre, erythema circinatum or an- 
nulare. As the lesion extends centrifugally zones of color may appear, or a 
new papule may develop in the depressed centre, and passing through a sim- 
ilar manner of evolution as the first papule form additional ring or rings, 
erythema iris; in this way from two to six rings may be produced varying in 
color with the order of their appearance. If a spreading ring of erythema 
meets other lesions, the parts brought in contact melt away leaving broken 
circles or multiple curves, depending in number and outline on the number 
of lesions which have come together, erythema gyratum. Again a section of 
a circle of erythema may resolve and the remnant continue to spread pro- 
gressively with an abrupt outer border, erythema marginatum ; this may ad- 
vance rapidly over a large extent of surface, leaving behind a degree of red- 
ness which gradually merges into pigmentation. The tendency to spread 
rapidly may show early in the papular stage by the quickly formed elevated 
plaques soon absorbing in the centre and their rims rolling out to join each 
other. 



132 ERYTHEMA EXUDATIVUM 

If the exudation is acute and intense enough the papules may become 
elevated into small or large wheal-like lesions, with marked itching or sting- 
ing sensations and often blood-capped excoriations due to scratching, ery- 
thema urticatum or lichen urticatus. As a result also, vesicles and bulla? may 
form on any of the lesions (erythema vesiculosum and bullosum), and oc- 
casionally they may appear to arise from the sound skin and intermingle 
with other primary lesions. Similar bullous lesions may appear on the mu- 
cous surfaces of the mouth and nose. The contents of vesicles or bullae may 
become bloody from hemorrhage into them, and occasionally their contents 
may become purulent. In a case of exudative erythema recently under obser- 
vation, a large number of secondary blebs formed and a few became purulent. 
On rupture of a bleb, the exposed surface had the appearance of a superficial 
ulcer without being depressed. The unruptured bullae dried into crusts, 
underneath which the surface was red and slightly moist. The patient was 
debilitated, but responded quickly to arsenicum. No scars formed. 

The eruptions of erythema multiforme often appear in crops and rarely 
the various phases of the disease may be witnessed in one case ; commonly the 
eruption is arrested at some intermediate stage and resolution sets in. More 
or less pigmentation succeeds the redness, gradually disappearing. Fre- 
quently the admixture of colors from congestion and stains gives a variegation 
of hues suggestive of the effects of contusions of the skin. 

The duration varies from one to five weeks. Seldom has the editor seen 
an attack last under treatment more than three weeks ; very rarely they may con- 
tinue for an indefinite period. Eelapses are common, and may be as frequent 
as every few weeks, or as far apart as annually, or at shorter or longer in- 
tervals. 

Erythema iris (Herpes iris). — An uncommon form of erythema always 
■characterized by the formation at some time in its course by central or con- 
centric vesiculation has been known as herpes iris; but as the vesicles are sec- 
ondary to congestive papules, it is now generally admitted to be a type of ery- 
thema multiforme, though occurring unassociated in its course with other 
forms. 

The usual features of an attack begin from twelve to twenty-four hours 
after the eruption of an erythema papule by the development of a pin-head 
sized vesicle in the centre of the papule. This enlarges in diameter with the 
papular swelling, but never to the full width of the latter, so that a reddish 
border is always present; the vesicle flattens in the centre, forming a depres- 
sion, around which is a ring of vesiculation and outside of that a reddish 
elevated border, and around all a narrow pinkish areola. Sometimes a vesicle 
is left in the centre with a circular depression around it, showing a slightly 
different clinical picture from that described. In perhaps an equal per cent, 
of cases, the vesiculation (in discrete or confluent form) may begin at the 
circumference of a papule or ring of papules in sharp contrast with the deep 
red elevated centre, herpes circinatus. Exudation may spread outside the first 
row of vesicles on which another circle of vesicles may appear, and so on until 






ERYTHEMA EXUDATIVUM L88 

a series of concentric rings may be seen in various stages of evolution, with tin- 
remnants of a sunken vesicle or a crust in the centre, and about all a more or 
less distinct red zone. In this manner lesions may reach the size of a half 
inch or more in diameter. Occasionally, in severe cases, two or more lesions 
may coalesce and form irregular patches; or, still rarer, small or large bulla? 
may form in place of the central vesicles, and there may be hemorrhage into 
their cavities. These cases may simulate pemphigus. 

The common locations of herpes iris are on the extensor surfaces of the 
'hands and fingers, wrists, insteps and knees; severe cases may have a more 
extended distribution, and appear on the flexor aspects of the extremities, the 
palms, soles, etc., or become generalized over the whole surface. The mucous 
membrane of the mouth, throat and conjunctiva may be involved, vesicles or 
crusts forming on the lips, the tongue and soft palate. Conjunctivitis and 
ecchymoses into the orbital connective tissue have been reported. 

The eruption of herpes iris occurs in crops, generally symmetrical, though 
the corresponding outbreak on one side may be later in appearance than the 
first. Its duration varies with the number of outbreaks, from one to four 
weeks; near relapses may, however, greatly prolong its duration. 

Erythema nodosum (Dermatitis contusiformis). — This form of exudative 
erythema occurs often enough with erythema papulatum or some other form 
of erythema multiforme to show its relation thereto; though in clinical type, 
it is usually a distinct affection. TJnna points out that the difference between 
this condition and erythema multiforme rests upon the fact that erythema nodo- 
sum never widens concentrically, never produces bullae and never exhibits 
annular vesicles. 

Most attacks begin with systemic rise of temperature of three or four 
degrees, pains in the joints of the legs, headache and general malaise. These 
symptoms, however, may be absent, except the articular pains of the lower 
extremities, with tenderness over the tibia, where the eruption nearly always 
appears on the second or third day. The lesions occur in crops of three or 
four symmetrical, roundish or oval, nodular swellings, which may vary in size 
from a cherry to a hen's egg, and merge in an ill-defined way into the sur- 
rounding tissues, which may appear somewhat cedematous. The nodules are 
firm but sore to the touch, and for one or two days after their advent are 
attended with sensations of aching, burning or stinging ; later they soften and 
appear to slightly fluctuate, but never rupture or suppurate. At first of a 
bright red or pink and white color, they become a dusky red, and passing 
through the ordinary changing colors of a bruise, "black and blue," they dis- 
appear in a week to ten days. New crops every few days may prolong the 
whole course for two to five weeks. Unlike the previously considered forms of 
erythema, recurrences are rare. 

Occasionally the disease may be located on other parts than the anterior 
tibial surfaces of the skin, such as the arms, face, back and thighs. In these 
situations the nodular lesions are likely to be smaller than those on the legs. 

Etiology and Pathology of Exudative Erythemas. — The predisposing 



134 ERYTHEMA EXUDATIVUM 

causes of erythema multiforme are age, sex, seasons ; anaemia, chlorosis, rheuma- 
tism, gout and other nutritive disturbances; malaria and the noxious emana- 
tions from defective drainage may be contributing or exciting factors. One 
attack creates a liability to others. The influence of age is such that the 
majority of eases occur between the ages of ten and thirty, and while no 
period of life is exempt it is extremely rare in early infancy or old age. I have 
seen only one case under one year and only two after the fiftieth year of 
life. Both of the latter were erythema papulatum of the hands and wrists. 
The female sex are more subject to all forms of erythema, probably because 
their nerve structures are more susceptible to disturbing influences. Change 
of seasons in the spring and autumn favor outbreaks. This is seen in recur- 
rences as well as in the first attacks. 

Anaemia of various kinds may so lower the resistance of the skin to ordinary 
causes as to permit an unusual effect of the latter on the skin ; or some element 
in the~blood or tissues, as in rheumatism, malaria, etc., may irritate the nerve 
centres and be reflected in congestion and exudation of the skin. 

The more common exciting causes appear to be exposure to heat, cold and 
winds; irritations of the genito-urinary organs from aggravations of disease 
or from instruments; various affections attended with primary or secondary 
infection of the system, such as diphtheria, septicaemia, cholera, variola, 
typhoid and typhus fevers, infectious endocarditis, uraemia, syphilis, influenza, 
etc. The ingestion of certain drugs at a time when the system is rendered 
susceptible by predisposing conditions or idiosyncrasy may excite outbreaks 
of exudative erythema. Of these may be mentioned quinine, chloral, antipyrine, 
copaiba, digitalis, arsenic, the iodine and bromine salts and mercurj r . Indi- 
gestion or irritations from certain articles of diet seem to promote outbreaks 
of multiform erythema, but in most all of the cases I have seen that could be 
attributed to the latter causes the eruption, while closely resembling some form 
of erythema multiforme, has had the ephemeral history of urticaria. Two 
cases recently under observation are of etiological as well as therapeutic inter- 
est: One, a middle-aged woman who habitually uses chloral at night for in- 
somnia, has every few weeks an eruption of quite typical erythema papulatum 
on the extensor surface of the extremities, which lasts for about two weeks, 
gradually resolving; the other, a young Irish girl, who recently arrived in 
this country, has had outbreaks for three weeks of a similar eruption on the 
extensor surfaces of the extremities, chest and face, but many of the lesions 
have come and disappeared within twenty-four hours, and none have lasted 
over three days. Probably her attack was induced by change of climate and 
diet. She has rapidly improved on simple regulation of diet and the adminis- 
tration of chloral. The editor has seen seven cases of multiform erythema 
occurring in emigrants just landed, in which the etiological factors were simi- 
lar to the case just mentioned. Osier has contributed some valuable data 
on the relations existing between the erythema group and visceral conditions, 
and has demonstrated that the cutaneous lesions are merely surface reflections 
of a visceral disorder. 



ERYTHEMA EXUDATIVUM 135 

Notwithstanding the multiple influences which may operate to produce 
erythema multiforme, there are many cases occurring without any ascertain- 
able cause, and are doubtfully idiopathic in pathogenesis. Perhaps in rela- 
tion to this disease, the latter term may be synonymous with idiosyncratic, 
for practically such cases respond most readily to indicated remedies. 

Regarding the pathology of erythema multiforme there is much difference 
of opinion. That it is a systemic disease, or sometimes due to infection, is 
generally entertained, but the theories that it is essentially infectious or a mere 
dermatitis are not proven by the clinical histories of most cases. That it is 
sometimes toxic and invariably angio-neurotic from the effect of varying and 
differently acting causes is the most plausible, though partial, explanation of 
its pathological inception. The tissue changes are confined chiefly to the upper 
parts of the corium and consist, in a less or greater degree, of an escape of 
serum, white and red blood corpuscles from the dilated vessels of the papillary 
and sub-papillary layers, which in the papular and tubercular forms, push 
outward the epidermis. If the pressure of the exudation toward the surface 
is great enough, serum is forced between the cells of the rete mucosum and vesi- 
cles or bullae are formed, covered by the more superficial layers of the epider- 
mis. An extravasation of blood from the vessels into the tissues may take place 
in some cases. Hebra advanced the theory that in erythema nodosum the mor- 
bid process was an inflammation of the lymphatic vessels. 

Other diseases may complicate the course of erythema multiforme or 
be consecutive to it, such as endorcarditis, pleuritis, affections of the kidneys, 
brain, etc. Local sequelae, such as boils, ulceration, abscess and gangrene, may 
occasionally follow. 

Diagnosis. — The characteristic features of erythema multiforme, the acute 
onset, symmetrical localization of the eruption on certain regions, its occur- 
rence in crops, persistence of individual lesions for several days, their chang- 
ing aspect, subsequent pigmentation, absence of marked sensations and ten- 
dency to recur annually, will generally suffice to distinguish it from other 
eruptive diseases. 

Urticaria lesions may occasionally simulate papular erythema; in fact, 
sometimes the two affections seem to intermingle, but nearly always lack of 
symmetry in distribution or any special localization of the eruption of urti- 
caria, the individual lesions seldom lasting more than one day, and the pro- 
nounced stinging or itching sensation, will determine the existence of that 
disease as compared with erythema papulosum. When the ordinary pink 
and white wheals of urticaria are present there is no difficulty, as they are 
pathognomonic. 

The papules of eczema are smaller than in erythema, persist longer and do 
not enlarge. Some may become vesicular, the itching is generally severe, and 
constitutional symptoms common in the early stage of erythema multiforme 
are absent. 

Rotheln often begins with moderate febrile disturbance, as is common 
to erythema multiforme, but the eruption of the former begins first on face 



136 DERMATITIS 

and extends over the body instead of being localized and limited in distribution 
as in the latter. The lesions of rotheln are rosy red and do not usually enlarge, 
and there is nearly always an attendant swelling, of the glands of the neck. 

The circular forms may be distinguished from psoriasis and ringworm 
lesions by their symmetrical distribution, absence of scaling and acute course. 

Erythema iris and herpes iris can hardly be mistaken for any other erup- 
tion, if their features as to situation, acuteness of evolution, etc., are borne in 
mind. Erythema nodosum has equally distinct features in the location over 
the anterior surfaces of the tibia (rarely over the ulna), of oval tender nodes, 
passing through gradations of color in their process of evolution. Syphilitic 
nodes of the secondary stage might objectively bear a close resemblance, but 
there would be almost invariably other evidences of syphilis present, as nodes 
are not likely to appear in the secondary period of mild cases. Tertiary syphi- 
litic nodules lack symmetry in arrangement and are slow in development and 
course^ and may exist a long time without redness of the skin. 

Prognosis. — Uncomplicated cases of erythema multiforme are nearly sure 
to get well in from one to five weeks, the more persistent cases leaving pig- 
mentations which gradually fade away. Any form is liable to recur, but ery- 
thema nodosum least of all. In complicated cases the prognosis must in great 
measure depend on the nature of the associated disease. 

Treatment. — No local treatment is needed in any form of erythema multi- 
forme beyond the comforting application of some mild alkaline water, cologne 
or alcohol and water. Causal treatment may call for physiological methods or 
pathogenetic remedies, or both; more often the latter is alone needed if the 
remedy is selected from indications furnished by the whole pathogenesis, 
whether it be idiopathic, symptomatic or blending with the symptoms of other 
pathological states. See indications for Aconite, Agar., Apis, Antipy., Arnica, 
Bell., Chin, sul., Chloral, Cicuta, Coca, Colch., Comocl., Copaiva, Dulc, Kali 
mur., Mer. viv., Nat. mur., N. phos., Rhus tox., Sal. acid, Sulph. acid, Urt. 
urens, Vespa. 

Erythema nodosum. — Am. mur.. Apis, Aurum mur., Bell., Juglans cin., 
Kali brom., Rhus tox., Sal. acid. Sulph. acid. 



DERMATITIS 

Under this head are grouped certain inflammatory affections resulting 
from certain definite causes. Nearly all are purely idiopathic; some are due 
to the same influences that produce idiopathic forms of erythema, acting with 
intensity enough or long enough to carry effects beyond the limits of conges- 
tion into that of inflammation, as evidenced by redness, heat and swelling. 
Thus, erythema caloricum, for instance, may become rapidly or slowly a 
dermatitis calorica. 



DERMATITIS CALORICA L37 



DERMATITIS CALORICA 

As the name indicates, this is an inflammation of the skin, resulting from 
the direct effects of extremes of temperature. When due to heat, it is termed 
dermatitis ambustionis, and when to cold, dermatitis congelationis. 

Dermatitis ambustionis may arise from various forms and degrees of 
heat, and the pathological degree of inflammation may vary from little more 
than an erythema to the production of serous exudation in the shape of 
blisters, or in extreme cases to gangrene, ulceration, and with recovery, exten- 
sive cicatrization. When produced by heat in dry form, as from the sun, 
by fire, hot solids, etc., it is termed a burn; and when by contact with hot 
fluids, such as water, oils, melted fats or solids, steam, etc., is known as a 
scald. 

The degree of dermatitis ambustionis is determined by the effects pro- 
duced on the tissues. In the first degree, the skin is red and inflamed without 
vesiculation. In the second degree, there is added vesicular or bullous exuda- 
tion. In the third degree, there is extensive destruction of the skin and some- 
times of the subcutaneous tissues and consequent scarring. 

Symptoms. — All forms of scalds and burns are exceedingly painful. In 
the first degree, the local sensation of burning, smarting, tension, etc., with 
swelling and redness, may comprise the symptomatology; in the second and 
third degrees, there may be more or less shock, rise of temperature and fre- 
quently consecutive congestions and inflammations of the viscera. These latter 
complications may take the form of gastro-intestinal disturbances, with bloody 
stools and vomiting of mucus and blood; intestinal ulcers may form, some- 
times ending in perforation, rapid peritonitis and fatal collapse. Severe burns 
about the chest or throat may be attended with bronchitis, pneumonia, pleurisy 
and obstructive laryngitis. Delirium, mania, convulsions or coma may appear 
as symptoms of cerebral congestion or effusions resulting from severe or ex- 
tensive burns or scalds. Even if the primary shock is overcome, sloughing 
of the injured parts, profuse and fetid suppuration, with or without the pres- 
ence of some complication, may soon produce alarming exhaustion; and 
nephritis, septicaemia or erysipelas may contribute to a fatal issue. If recovery 
follows from burns of the third degree cicatricial formations and their subse- 
quent contractions are often disfiguring and distressing enough to call for 
plastic operations, skin grafting, etc., for relief. 

Diagnosis and Prognosis. — There is seldom any difficulty in distinguish- 
ing dermatitis ambustionis from the history of a case, and whether from 
a burn or scald is not practically important, though usually ascertainable. 
Of more moment is it to determine the extent and degree of the burn. On 
this largely rests the 'prognosis. The wider the surface involved, even in the 
first degree, the more doubtful is recovery. Burns of more than one-third of 
the surface are generally fatal in a few days. Deep burns of the skin, if cir- 
cumscribed, are less grave than superficial burns of a wide area. The most 



138. DERMATITIS CALORICA 

unfavorable locations are the chest, neck and abdomen; the most favorable, 
the more they are limited and confined to the extremities. Extremes of age 
are unfavorable, as are also debility, constitutional weakness and delicate 
organization. 

Treatment. — The local dressings for burns and scalds should give me- 
chanical protection, and in case of vesiculation or destruction of the skin, 
perfect asepsis. For burns of the first degree of small or large area, the follow- 
ing will be found useful : 

R. Picric acid 5 2. 

Alcoholis 5 4. 

M. et add. 

Sterilized water 3 40. 

The affected surface should be gently wiped over with the solution, then 
completely covered with gauze saturated with it, and a bandage applied to 
keep the dressing in place. As a rule, it can remain undisturbed for four days, 
when it may be softened with the same solution, the dressing removed and a 
fresh one applied. When the inflammatory action is more intense boro- 
glyceride ointment may be employed. 

R. Boro-glyceride 50% 3 2. 

White wax, 

White vaseline aa 5 12. M. 

This may be thoroughly applied to the affected surface and covered with 
several layers of sterilized gauze, held in place by a binder or bandage, as is 
best adapted to the location. Carbolized olive oil or vaseline (three to six per 
cent.) can be substituted for the above, when the surface involved is not too 
large. Bicarbonate of soda is a convenient application, which can be dusted 
thickly over the surface and covered with moist cloths and a bandage. An- 
other dressing usually at hand, for superficial burns, is sugar and water made 
into a syrup, smeared over the surface, and covered with gauze moistened with 
oil or fat to prevent too firm sticking of the latter. Both of the above domestic 
applications are said to relieve the painful sensations and to yield good results. 
The same may be said of equal parts of sweet oil and lime water or "carron 
oil." Thiol or ichthyol can be employed for burns of all degrees, dissolved in 
an equal part of water for cases in which the skin is unbroken, and in two to 
four parts of water for more severe burns or when there is much inflamma- 
tion. Whatever strength is used, it should be painted over the affected surface, 
covered with layers of gauze saturated with oil, over which may be placed oil 
silk or rubber tissue. Creolin, one to two per cent, in glycerine, is often ser- 
viceable in relieving the more intense inflammation and pain. Gauze can be 
saturated with it and directly applied. 

When blisters form, and are full or tense, they can be drained off by punc- 
ture at their most dependent border, in order to save the roof wall of the 
blister, which, falling in contact with the surface underneath, may not only 



DERMATITIS CALORICA 13 ( J 

protect it from the air, but possibly serve as a natural graft in the renewal 
of the epidermis. When serous exudation has ceased, a dressing found com- 
fortable may be continued, or an ointment like the following may be found 
more serviceable: 

R. Aristol 31. 

Sweet oil 3 1. 

Mix until dissolved, and then add 

Simple cerate 5 1. M. 

This may be applied directly to the surface and covered with aristol gauze 
and a bandage. Europhen or nosophen can be substituted for the aristol with 
advantage when the affected surface is unusually dry. Tincture of cantharides, 
•one to twelve parts of sterilized water, is a useful application when burning is 
excessive, and the drug is indicated internally. Small areas of unbroken skin 
may sometimes be painted over with flexible collodion for quick effect. Sue. 
calendula, one to ten of "carron oil," is most effective in promoting repair 
after the more acute stage is passed. 

Dermatitis ambustionis, with destruction of the skin, either suppurative or 
gangrenous, demands strict local antisepsis from the first. A five per cent, 
solution of carbolic acid can be used to disinfect the surface, followed by 
lightly dusting over the more deeply burned surfaces, if not too large, with 
powdered aristol, iodoform or nosophen, and dressing the whole affected surface 
as directed for burns of the second degree. If the area involved is extensive, 
applications for a time of borated gauze, kept wet with a five per cent, solution 
of biborate of soda, may follow the carbolic acid solution, enveloped with 
abundant layers of dry antiseptic lint, covered with rubber cloth. Some of the 
•oily antiseptic dressings may be substituted when inflammation subsides or 
healing has begun. Dressings should only be removed when necessitated by 
the accumulation of exudation and to relieve suffering. In deep burns of the 
-extremities or into joints, amputation of parts may be required, and other 
surgical (plastic, etc.) methods may be needed to promote healing, or later to 
relieve cicatricial deformities, etc. 

In burns and scalds of all degrees, internal treatment may be of the 
first importance. Shock may need to be combated and prevented. The sup- 
porting and steadying effects on the nervous and circulatory system of the 
primary action of opium may be of much value here ; morphine by hypodermic 
injection in doses and frequency to meet the needs of a patient is the prefer- 
able mode of administration, always giving the minimum physiological dose 
until the susceptibility of the individual to the drug is known. It is some- 
times surprising how small a dose is required for the purpose named. It 
further modifies the local pain, and except for burns of small size, is to be 
relied on more than the ephemeral effects of local applications of a solution 
■of cocaine. General supporting treatment and stimulation when needed 
should not be neglected in cases where exhaustion is likely to be a feature. 
Much can be done by internal medication to lessen the severity of burns, to 



140 DERMATITIS CALORICA 

forward healing and modify a tendency to excessive cicatricial formation. See 
indications for Arnica, Cantlmris, Kali mur., K. phos., Silicea, Sul. acid, Urt. 
wens and Graph., while cicatrization is under way. 

Dermatitis congelationis (Chilblain; Frostbite; Pernio; Erythema 
Pernio) . — Inflammation of the skin caused by cold, like those dne to heat, may 
be of three grades. In the mildest form there occurs, from a sufficient chill- 
ing, a whitening of the skin in patches, with partial or complete loss of sensa- 
tion therein. With the return of warmth there is burning, pricking or itching 
of the parts, which soon become intensely red; followed usually by a gradual 
disappearance of the color and other symptoms. In persons of weak circula- 
tion, such exposure often leads to a more persistent type of inflammation, 
especially on the digits or other borders of the hands and feet, commonly 
known as chilblain. The color of the affected skin is a purplish or bluish red, 
often cool to the touch, though sensations of heat, smarting, etc., are felt, 
especially when warmed after a chilling. 

In the second grade of dermatitis from cold, there is produced with the 
reaction vesicles or bullae, the contents of which often become bloody, and 
ulcers are liable to result. 

The third degree of effect from intense or prolonged cold causes more or 
less death of the frozen part, with or without the occurrence of blisters of the 
second grade. Sensation in the affected tissue is lost ; the surface is first whit- 
ened, but during forty-eight hours after the removal of the cold, swelling 
gradually appears, the color changes, and a line of demarcation forms, followed 
by the usual signs of mortification and separation by ulceration. 

Diagnosis and Prognosis. — Cases of frostbite come to the practitioner 
already diagnosed. In the milder forms recovery is almost certain under 
proper treatment. Chilblain has a tendency to recur with the return of cold 
weather until the cure is permanent. In the severer forms, it is to be borne in 
mind that deformity from loss of tissue or by operation to remove gangrenous 
parts is always a liability, and that shock may complicate the process at any 
stage. 

Treatment. — Milder forms of frostbite and chilblains may be treated 
mechanically by friction with cooling applications of alcohol, cologne, bay- 
rum, menthol solution, peppermint or camphor water, etc., care being taken 
to protect the parts subsequently from further exposure or undue pressure. 

For the severer forms, the local treatment is decidedly isopathic — cold for 
the effects of cold should here be the invariable rule. The patient must be 
kept in a cool room, and efforts made to slowly restore the circulation to the 
frozen parts by frictions with snow, or ice water, continued for hours where 
there is any hope of a return of the blood supply. If blisters develop, they may 
be emptied of their contents, and some of the cooling applications named 
above applied until it is learned whether or not mortification is to follow. 
If the latter result affects the extremities, early amputation may be necessary 
to save life, and if impracticable or delayed, antiseptic dressing may be 
applied. With the re-establishment of the circulation the surroundiug temper- 



DERMATITIS TRAUMATICA— RONTGEN RAY DERMATITIS 141 

ature can be raised and hot nutrient liquids (or stimulants if needed) given 
to the patient. The subsequent treatment of favorable cases is mainly pro- 
tective, and for some time after recovery exposures to severe cold should be 
carefully guarded against. Considerable assistance may be expected from the 
administration of indicated remedies. See Agar., Borax, Cadmium sul. Carbo 
vcg., Crotal., Ilepar, Kali mur., Lye, Nat. phos., Sulphur, Sul. acid. 



DERMATITIS TRAUMATICA 

Differing degrees of injury or mechanical irritations of the skin from 
blows, pressure, frictions, scratching, etc., cause different grades of inflamma- 
tion. Whatever the traumatism may be, not requiring surgical measures, a 
removal of the cause and mechanical protection of the surface is usually all 
the treatment required. Pigmentation and thickening of the skin may result 
from long continued irritation and pressure. Arnica, Graph., Hepar, Hyper- 
icum and Sul. acid are suitable remedies when needed. 



RONTGEN RAY DERMATITIS 

This inflammatory condition which was quite common in the early days of 
the employment of the X-rays, is occasionally developed in the practice of 
careful and experienced operators even in this day of scientific precision. 
The mildest cases develop an erythema, often followed by pigmentation ; or 
vesiculation may occur, and in severer types a dry superficial slough forms 
which takes months to separate, and may result in an ulcer which in turn 
takes months and even years to heal. These serious lesions are surrounded 
by an inflammatory border and accompanied by pain. The cicatrix which 
eventually forms may be covered with telangiectases. A chronic form, occurring 
on the face and hands of X-ray operators, is characterized by scaliness, atrophy, 
obliteration of the normal lines of the skin, alopecia and at times loss of 
-the nails. 

Long exposures for skiagraphic purposes, frequent applications for thera- 
peutic relief, the quality of the tube or personal idiosyncrasy play the etiologi- 
cal roles. It is well to remember that even if, after erythema develops, the 
treatment be discontinued, the dermatitis may develop, sometimes two weeks 
or more having intervened since the discontinuance of treatment, and that 
the effects are cumulative. In some instances, to obtain the desired effect, 
an X-ray dermatitis must be obtained. The editor has treated cases of ony- 
chomycosis, psoriasis of the nails, epithelioma and lupus -vulgaris which did 
not respond to tr.eatm.ent until a dermatitis was set up. In each case the final 
results were satisfactory. 

Pathology. — A degeneration of nucleus, as well as the cell protoplasm, 
involving not only the epidermis and its appendages but also the corium, may 
result from the use of the X-rays. The fibrous and muscular elements may 



142 DERMATITIS MEDICAMENTOSA 

become involved, and, if an inflammatory reaction sets in, the blood-vessels 
become dilated, extravasation of serum and leucocytes result, the latter in turn 
becoming phagocytes and destroying the degenerated cells. 

Teeatment. — Improved methods of technique have lessened the frequency 
and intensity of these cases. The milder forms of erythema need protection 
and possibly a cooling lotion of lead and opium with or without the addition 
of glycerine or boric acid. Two to five per cent, of creolin in glycerine has 
sufficed for more intense cases. Carron oil (made with olive oil), or an oint- 
ment containing orthoform one or two drachms to the ounce of simple cerate, 
have been recommended. Surgical treatment is to be recommended in deep 
ulceration where the necrosed tissue must be excised and skin-grafting re- 
sorted to. 



DERMATITIS MEDICAMENTOSA 

(Drug eruptions; artificial eruptions, etc.) 

Any substance which commonly produces inflammation of the skin, either 
from internal administration or local contact, may possibly have medicinal 
properties and uses. Some drugs affect the skin in a similar manner whether 
used internally or externally; others onty or chiefly when employed in the 
former way, and still others produce lesions of the skin largely from external 
contact. Variations in the effect of substances on the skin are also in a 
measure due to the inherent differences in the skin itself of different indi- 
viduals, idiosyncrasy, etc., as well as to the quantity and quality used and 
frequency of repetition. From these brief considerations it will be seen 
that it is impracticable to divide the pathological effects of substances upon the 
skin according to their method of application. Clinically it is convenient 
to group under dermatitis venenata the more common and purely external 
effects of drugs with other substances which produce externally lesions of the 
skin; since they all act in the same way by irritation of the sensory peripheral 
nerves, causing vascular dilatation from vaso-motor paralysis, either direct 
or reflected from the spinal centre. When produced purposely to deceive 
others, such lesions are known as artificial or feigned eruptions; and when 
incident to certain occupations, trade eruptions. Leaving to be included under 
the term drug eruptions the effects of drugs on the skin from absorption into 
the system by the stomach or otherwise, the effect only differing from the 
degree of absorption whether by the skin, stomach or other mucous surface. 

Drug eruptions. — Nothing, perhaps, in the whole range of the observed 
effects from drugs on the human body confirms their analogous relations to 
the pathological features of disease and their adaptability under scientific 
principles in the treatment than the fact that they may produce, under favoring 
conditions, nearly all the primary lesions which occur in skin diseases. With 
few exceptions, the effects of drugs upon the skin are not constant or the same 
in different individuals, or on the same person at different times. This is 






DERMATITIS MEDICAMENTOSA 143 

also true in regard to the great majority of the causes of the so-called natural 
diseases. Exceptionally the drug action on the skin is nearly constant and 
specific, as are the actions of specific causes of disease. Further analogy can 
be shown in varying degree in symptomatology. The local subjective sensa- 
tions are usually itching, burning and tingling, which may precede, attend 
or follow the outbreak of the eruption. Systemic disturbance may be absent, 
or fever, headache, etc., similar to the onset of eruptive fevers, appear. Long- 
continued, some drugs may lead to grave constitutional symptoms or even 
to death. 

The varied and multiple lesions caused by drugs, their combinations and 
arrangement most often simulate the exanthemata, but may resemble many 
other forms of cutaneous disease. It is important that the general practitioner 
should be familiar with the skin changes produced by drugs, especially those 
which more or less closely resemble eruptive fevers. 

Drug eruptions may appear rapidly or slowly; commonly the congestive 
and exudative forms appear promptly, and the more typical inflammatory 
lesions, like those from iodine and bromine salts, slowly or after long use 
of the drug. More drugs produce erythema than any other lesion; next in 
order of frequency are vesicles, papules, wheals, bulla?, pustules and tubercles; 
while pigmentations, gangrene, hemorrhages and marked desquamations are 
rarer effects. Some few drugs may produce nearly all varieties of lesions, 
others only give rise to one or a few forms. 

Aconite sometimes causes a reddish, hot, swollen state of the skin, resem- 
bling erysipelas; or vesicles, bullae, wheals and pustules may follow its use. 

Ailanthus produces a punctate erythema of a dark red or purplish color, 
especially on the face. 

Amygdala amara (bitter almond) has caused erythema and wheals, from 
both internal and external use. 

Anacardium has a very pronounced inflammatory action on the skin, which 
shows in erythema and swelling (erysipelaform), or vesicles, papules, pustules 
and bulla?. In a case under the author's observation, a generalized eruption 
of patchy erythema, on which were situated small papules and vesicles with a 
few warty-like lesions, occurred from doses of anacardium tincture. 

Antimonium crudum and tartaricum have produced vesicular, pustular 
and wheal-like eruptions. Some of the pustules (from the tartrate) were 
deep-seated like boils, and some left bluish red stains (face). Crude antimony 
long continued may cause papillary excrescences. 

Antifebrine (or acetanilid) shows its toxic action often by producing a 
cyanotic erythema or discoloration of the skin. 

Antipyrine and others of its class (manufactured from the petroleum 
products by the action of glacial acetic acid) have caused many times erythe- 
matous macules, most often resembling measles, less often papules and wheals, 
and occasionally blisters, pustules (furuncular) and purpuric spots. With the 
outbreaks there may be profuse perspiration, and the macular eruption may 
be followed by desquamation and pigmentation. 



144 DERMATITIS MEDICAMENTOSA 

Antitoxins and other inoculation injections may be followed by cutaneous 
reactions or lesions. Practically little is known as yet of the exact near and 
remote effects of these products on the skin, if we except vaccination. Tuber- 
culin rash may be scarlatiniform, morbilliform or in irregular patches scat- 
tered here and there about the trunk. Subjective sensations may be slight or 
absent, but desquamation sometimes follows. Several cases of generalized 
psoriasis have been reported as following tuberculin injections in the treat- 
ment of leprosy. Diphtheria antitoxin causes erythematous, scarlatiniform, 
morbilliform, urticarial or purpuric eruptions in an appreciable number of 
cases. Tetanus antitoxin injection is reported to have caused an urticarial 
eruption which persisted for thirty-six hours. 

Apium virus produces a generalized eruption of wheals, or an erysipelatous 
redness and swelling, and sometimes a deep red erythema. 

Arsenicum and preparations containing arsenic in some form, have pro- 
duced-nearly every form of skin lesion in many and different cases, so arranged 
as to simulate a large number of cutaneous diseases. Erythema, papules, 
vesicles (zoster), wheals, pustules (furuncular and carbuncular ) , hemorrhagic 
spots (petechia?), grayish or brownish discolorations, scales (psoriasiform). 
The editor has seen one case of generalized psoriasis apparently produced 
primarily by toxic doses of arsenic, and in which secondary attacks of the same 
arose from moderate doses of the same drug, and a number of cases of general- 
ized pigmentation suggestive of Addison's disease, occurring in children who 
have received large doses of arsenic for chorea. Thickening of the palms and 
soles (keratosis) has been noted from its use. Externally arsenic has a de- 
structive effect on the skin, producing gangrene and ulpers. 

Arum (Indian turnip) produces a scarlatiniform erythema, which is fol- 
lowed by flaking of the skin, simulating with its throat symptoms severe 
scarlet fever. 

Aurum metallicum and the salts of gold, when prepared for medicinal use, 
and given internally in sufficient doses, may produce pustules, wheals or nodos- 
ities, which on the lower legs may simulate erythema induratum or syphilitic 
formations. 

Belladonna produces a diffused scarlatiniform erythema, which may tend 
to assume an erysipelatous type of inflammation, and rarely as the effect of 
continued hsemostasis circumscribed gangrene may occur. Atropine solutions 
used in the eye have by absorption or reflexly produced erysipelatoid forms 
of inflammation of the lids and face, with vesicles and sometimes pustular 
lesions. 

Benzoic acid internally may cause erythema, ervthemato-papular or wheal- 
like lesions. 

Borax has produced morbilliform erythema, or diffused erysipelatous red- 
ness, eezematous eruptions, papules, vesicles and pustules. From long use in- 
ternally, squamous lesions develop strikingly like the scaling patches o-f 
psoriasis. 

Bromine and its salts produce a characteristic eruption known as "broinic 






DERMATITIS MEDICAMENTOSA 145 

acne/' affecting the parts of the skin most abundantly supplied with sebaceous 
glands, showing the same preference in a general way as the lesions of acne 
vulgarus. Vesicular lesions resembling varicella may appear, also pustular 
formations — small, i'uruncular or carbuncular in type. Erythematous, urti- 
carial, nodular, bullous, papillary, fungoid and nondescript lesions may occur 
singly or in various combinations. 

A characteristic bromide of potassium eruption, usually occurring in infants 
or young children, has been carefully studied. The lesions are condylomaform, 
varying in size from large peas to a cherry, with a narrow areola about them. 
Other large lesions had a central depression, resembling molluscum, which later 
broke down and formed elevated, irregular' ulcers. This eruption may appear 
some weeks after the drug has been discontinued. Crocker says he has seen 
bromide eruption occur in scar tissue, and in two cases was limited to the 
cicatrices. 

Bryonia may cause a diffused elevated eruption of erythema, papules and 
vesicles widely distributed. A few pustules may also appear. 

Calcarea carbonica, given internally, may produce wheals (sometimes 
linear), wart-like lesions, and eczematous forms of dermatitis. 

Calcium sulphide causes well known eruption and conditions of the skin. 
Wheals, erythema, vesicles, pustules and hemorrhagic spots may rapidly occur 
on previously healthy skin ; or furuncles and other pus formations may appear 
in the neighborhood of other lesions. 

Cantharides absorbed by the skin or from internal administration may give 
rise to generalized erythematous pustules or erysipelatous redness with vesicu- 
lation, and eczematous papules with burning and itching sensations. 

Capsicum may cause an erythema or a papulo-vesicular eruption. 

Carbolic acid, when absorbed, may cause outbreaks of vesicles all over the 
body, sometimes changing to pustules; also, erythema; becoming generalized, 
with or without other lesions. Pustules and fissures may form, and from 
severe effects gangrene may result. 

Chloral hydrate, used internally, causes various eruptions, most often 
erythematous, and then frequently morbilliform or searlatiniform in appear- 
ance. At the same time the conjunctiva and throat may be congested, making 
the resemblance to measles or scarlet fever still more pronounced. Occasionally 
the patches of redness may be few and circumscribed. Vesicular, papular, 
urticarial, furuncular, carbuncular, purpuric lesions have been observed, and 
ulcers of the skin, cornea and tongue noted from the use of chloral. 

Chloralamid is reported to have caused a diffused punctate erythema with 
the development of vesicles, attended with coryza and fever and followed by 
desquamation. 

Chloroform, inhaled, has caused a mild erythema and rarely purpuric spots. 

Chrysarobin eruptions from external contact and from absorption are a 
coppery-red dermatitis, which about the face may close the eyes and present a 
general likeness to erysipelas. In one case it resembled dermatitis exfoliativa, 
lasting for months. Vesicular, papular and pustular lesions have also occurred 
from its use. 



146 DERMATITIS MEDICAMENTOSA 

Cicuta virosa, though seldom given in material doses, may, when used, 
cause erythema and large papules or tubercles on face and hands, like some of 
the eruptions of erythema multiforme. 

Cinchona and its derivatives, especially quinine, frequently cause cutaneous 
lesions of various kinds. Quinine most often gives rise to a scarlatiniform 
erythema, which may be followed by desquamation or exfoliation of the epi- 
dermis. Sometimes the rash is more like measles, or it may be urticarial, ery- 
sipeloid, vesicular, bullous or purpuric in character. Gangrene of the scrotum 
has been observed from quinine in moderate doses. All forms of eruption are 
usually attended with itching or pricking sensations, and often there is a rise 
of systemic temperature to 101°-102°. 

Conium may cause papular pustular lesions, erysipelas-like erythema, and 
sometimes inflammation and ulceration about the finger nails. 

Condurango. — Guntz reports furuncular and acneiform lesions in twenty 
patients out of one thousand who were receiving this remedy for syphilis. 

Copaiba and cubebs used internally produce similar eruptions, or rather 
the urticarial eruption of the latter is like one of the more numerous lesions 
of the former. A morbilliform rash occurring chiefly on the more distant 
parts of the extremities, the abdomen and chest, is the usual form of 
eruption, but it may be urticarial, papular, vesicular, bullous, or petechial in 
form. 

Creosote may cause patches of redness with scaling, something like the 
lesions of seborrhoeic dermatitis; also, wheals, vesicles and pustules; the latter 
may resemble small-pox lesions. 

Digitalis does not often cause lesions of the skin. Scarlet forms of ery- 
thema, or darker red, as in erysipelas, vesicles, papules, and wheals have been 
observed from its internal use. 

Dulcamara has produced an eruption of wheals with a purplish erythema, 
without attendant fever, indicating a languid circulation. 

Euphorbium and other resins taken in the system cause eruption of the 
skin. The first named has produced an erysipelatous swelling and redness of 
the face and scalp, with vesiculation, throbbing pain and fever. Pustules, 
ulcers and gangrene have been reported as effects of this resin. 

Ferrum iodid from internal administration has caused acnoid eruptions 
on the face, back and breast. Erythema, wheals, vesicles and pustules have 
been observed from its use. 

Graphites prepared for medicinal use and absorbed into the system in suf- 
ficient quantity has a pronounced effect upon the tissues of the skin, which 
show in eczematous itching blotches, with oozing of sticky, irritating fluid 
on various parts of the body. A more gradual or secondary effect is seen 
in dry. thickened skin, which cracks easily. 

Hydrastis has caused eruptions on the face, especially about the mouth, 
which have gone through a similar evolution as the lesions of varioloid: also, 
erysipelatous and intertrigo types of erythema. All its eruptions are attended 
with burning, sometimes very severe. 



DERMATITIS MEDICAMENTOSA 147 

Hyusi //a in us eruptions may follow from internal doses. (Edema with 
redness and wheals, or a purplish rash have been observed; also, purpura- 
like lesions, vesicles resembling chicken pox, pustules and gangrenous spots. 

Iodine and its com pounds, by the stomach or other absorption, may cause 
nearly all the primary cutaneous lesions. The pustular forms are most com- 
mon, and like the bromine eruptions show a preference for portions of the 
skin richly supplied with oil glands; they are not, however, limited to these 
regions. They may be discrete, or grouped closely together to form a car- 
buncular appearance, which, if the cause continue, may take on a papillomatous 
growth. Erythema (simplex and nodose), vesicles, bullae (sometimes of large 
size), petechias or other purpuric lesions may follow as an effect of this drug. 
Often various lesions commingle together, and may be present in form difficult 
to classify. 

Iodoform taken internally or absorbed through wounds, may give rise to 
macules, papules, vesicles, bullae or mixed eruptions. 

Ipecac, internally, has caused a generalized, fiery-red erythema, in circular 
patches with elevated borders, something like erythema circinatum or annular- 
atum. Wheals and vesicles were also observed. 

Iris versicolor has produced vesicles and pustules on the face and wrists 
with subsequent crusting, which in association with a neuralgic pain stimulates 
somewhat attacks of zoster. 

Jaborandi or pilocarpine express their greatest effect on the sweat glands 
in hyperidrosis, but circumscribed erythema, minute papules, vesicles and 
wheals have been observed from their use. 

Ledum (wild rosemary), used internally, may cause red papules, vesicles 
and pustules, especially on face and forehead, with considerable attendant 
itching, biting and raw sensations. 

Lycopodium in medicinal form and doses may cause in sensitive persons out- 
breaks of erythematous, vesicular and pustular lesions with raw surfaces, 
which itch, burn and easily bleed, thus resembling eczema, intertrigo, herpes, 
etc. 

Mercury and its salts locally produce destructive inflammation of the 
skin; (see trade eruptions). Absorbed into the system, it may produce a 
variety of lesions ; erythema, vesicles and pustules with acrid contents, wheals, 
bullae, circumscribed abscess (furuncular), superficial and widespread ulcera- 
tion. From absorption from inunctions, a universal exfoliative dermatitis has 
been observed. Many of the mercurial eruptions resemble the lesions of 
syphilis. 

Mezereum produces disturbances of the skin and other tissues somewhat 
resembling those of mercury. Its vesicles and pustules usually go on to 
abundant exudation, which dries into thick whitish-yellow crusts, under 
which the moist exudation continues and the inflammation tends to spread 
in all directions. If ulcers form, they are sensitive, bleed easily, and the free 
secretions form heavy, sometimes elevated crusts. 

Nitric acid, in full doses of the dilute form, may produce circumscribed 



148 DERMATITIS MEDICAMENTOSA 

swelling and redness of the skin like chilblain or erysipelas; fine vesicles and 
pustules, which may simulate carbuncle, or if excoriated may form ulcers with 
irritating discharge. 

Nux vomica and strychnia in sufficient doses internally may excite erup- 
tions of erythema (scarlatiniform), vesicles, papules and pustules (acne-form). 

Oil of sandalwood in medicinal doses has caused simple forms of erythema 
and petechial-like hemorrhages of the skin. 

Olium morrhua? may give rise, when used internally, to erythemato-ves- 
icular lesions of the skin, or acneform papules. 

Olium ricini, in full doses, has produced a pruritic erythema similar to that 
type of eczema. 

Opium and its alkaloids, absorbed into the system, may produce varieties 
of erythema (scarlatiniform, morbilliform, exudative, or a cyanotic flush). 
Of these the exudative is the most common. Wheals, vesicles, pustules (furun- 
cular— or carbuncular), sometimes oedema of eyelid and face, with itching, 
biting or tensive sensations, are not uncommon effects of these preparations; 
while erysipelas-like inflammations and indolent ulcerations have been noted 
as extreme effects. 

Phenacetine is recorded as producing an erythematous rash, most marked 
on the extremities. 

Phosphorus and phosphoric acid, from full medicinal doses, may show their 
effects on the skin in diffused or circumscribed redness, grouped vesicles, wheals, 
pemphigoid bulla?, pustules (sycosiform, furuncular or ecthymaf orm) , pur- 
plish maculations and peach colored stains; while in persons sensitive to 
the drug or from poisonous doses purpuric extravasations may appear, or 
other lesions become hemorrhagic and bleed easily. 

Piper methysticum (kava kava), which is used as an intoxicant beverage 
by native South Sea Islanders, is said to produce a redness and dryness of 
the skin, with desquamation in large or branny scales, leaving white spots 
on which trophic ulcers may form, resulting in scars. The dry skin may 
become thickened and fissures form. Some phases of the eruption are said to 
resemble leprosy of the skin. 

Plumbum and its salts absorbed into the system may cause erythematous, 
vesicular, pustular and purpuric lesions. 

Pulsatilla nigricans sometimes causes rubeoloid and urticarial eruptions 
of the skin, probably as a reflex of its more powerful action on the mucous 
structures. 

Potassium chlorate internally has caused erythema (multiform), vesicles, 
papules and pustules with pruritic sensations ; and from long administration, 
purple macules and cyanotic duskiness, worse on lip and extremities, have been 
observed. 

Ranunculus bulbosus produces in sensitive persons a characteristic, grouped 
vesicular eruption, which in association with neuralgic pain simulates very 
closely herpes zoster. The vesicles become opaque, or they may become hemor- 
rhagic or purulent and resemble unusual forms of vesicular erythema or 
eczema. 



DERMATITIS MEDICAMENTOSA 149 

Rhubarb may produce a recurrent scarlatiniform erythema, generalized 
over the whole surface and followed by desquamation. 

Santonin from internal use, will sometimes excite outbreaks of general- 
ized urticarial lesions with some associated erythema and oedema of the 
skin. The lips and eyelids may he greatly swollen, and desquamation may 
follow the primary eruption. 

Salicylic acid and salicylate of soda in maximum doses may cause erup- 
tions of erythema, vesicles, bulla?, wheals, pustules, petechia? and vibices; in 
one case gangrene of the legs occurred from its use. Phases of erythema 
multiforme are probably the nearest types of cutaneous disease caused by 
these drugs. Sdlol has caused urticarial eruptions. 

Sarsaparilla long continued internally, may cause roseola-like macules, 
herpetic lesions on many parts of the skin, which, if ruptured, emit an acrid 
discharge. Persistent use may cause papillary or wart-like elevations of the 
skin. 

Secale (ergot), administered internally, may cause eruption of vesicles, 
pustules (furuncular and anthracoid) ; with swelling and haemorrhages (pete- 
chial and ecchymotic), changing into gangrene. Its effect on the cutaneous 
circulation may show primarily in blueness and coldness of the parts (usually 
on the extremities), with disturbance or loss of sensation, and finally gangrene. 

Staphisagria shows its effect on the skin by miliary papules and vesicular 
eruptions, the latter resembling herpes and sometimes zoster occurring in 
the scorbutic, and the former looking something like lichen scrofulosus. 

Stramonium efflorescence from internal use is a bright scarlatiniform 
or darker red, like erysipelas. Petechial, vesicular or pustular lesions may 
occur with, or as the erythema subsides. 

Sulplional, in ordinary hypnotic doses, may cause a symmetrical scarlet 
eruption, attended with intense itching and followed by desquamation. Pur- 
puric lesions on the extremities and medium-sized red spots on the trunk, 
simulating syphilitic roseola, have been noted from its use. I have seen rose 
spots over the abdomen, chest and legs, nearly identical in appearance with 
the rose spots of typhoid fever, follow the administration in one night of 
eighty grains of sulplional in divided doses for a case of protracted insomnia, 
incident to an attack of the grippe. The eruption disappeared within forty- 
eight hours, leaving no trace. 

Tanacetum (oil of tansy), after absorption into the system, has produced 
an eruption on the skin resembling small-pox lesions. 

Thuja may cause the outgrowth of papillary or wart-like excrescences, 
which bleed easily when irritated. 

Turpentine (terebene), used internally, may occasion eruptions of bright 
red erythema, chiefly on face and upper portions of the body; fine papules, 
sometimes vesicles and pustules with itching and other eczematous features. 
Terebene has produced an abundant bright red eruption of papules with in- 
tense itching. 

Valerian, in medicinal doses, has caused urticarial papules and wheals 



150 DERMATITIS MEDICAMENTOSA 

to appear on the skin, and sometimes a central vesiculation as in erythema 
vesiculosum. 

Veratrum viride, given internally, has caused a painful form of congestive 
erythema, not unlike erysipelas. Pustules on the face have also been seen 
as a result of its use. 

The foregoing does not include all the drugs which may cause skin erup- 
tions, nor the more subtle drug effects which may arise from small doses, 
which are of therapeutic, rather than diagnostic value. 

Vaccination eruptions have been etiologically classified by Malcolm Morris 
in practical form, the correctness of which is confirmed in some degree by my 
own experience. His tabulation is reproduced here : 

Group 1. — Eruptions due to pure vaccine inoculation: 

A. Secondary local inoculation of vaccine. 

'3> Eruptions following within the first three days before the development of vesicles. 
Urticaria. 

Erythema multiforme. 
Vesicular and bullous eruptions. 

C. Eruptions following after development of vesicles due to absorption of virus. 

r Roseola — like measles. 

1 . < Erythema — like scarlet fever. 
\ Purpura. 

2. Generalized vaccinia. 

D. Elruptions appearing as sequelae of vaccination: eczema, psoriasis, urticaria, etc. 

Group 2. — Eruptions due to mixed inoculations: 

A. Introduced at time of vaccination. 

a. Producing local skin diseases. 
Contagious impetigo. 
Erythema. 

b. Producing constitutional disease. 
Syphilis. 

Leprosy? 
Tuberculosis? 

B. Introduced, not at time of vaccination, but subsequently through the wound. 

1. Erysipelas. 

2. Cellulitis. 

3. Furunculosis. 

4. Gangrene. 

5. Pyajmia. 

Every physician whose observation of disease covers a period of twenty or 
more years will readily recall many of the simpler types of vaccination 
eruptions. Generalized vaccinia and erysipelas are of exceptional occurrence; 
syphilis, cellulitis, gangrene and pyaemia are very rare; and leprosy and 
tuberculosis are only possible results from infection inoculation. These and 
many of the other eruptions are preventable, and seldom seen in these later 



DERMATITIS MEDICAMENTOSA 161 

days. While the near and remote sequelae (Group 1. D.) from vaccination 
might, and probably will, be greatly extended. 

If inoculation with vaccine virus leaves so profound an impress upon 
cells as to render them immune to the influence of another virus, it is not 
illogical to assume that the same qualitative protection against one disease 
may be counterbalanced by a lessened resistance against morbific influences 
tending to the production of other forms of disease, or beget a modified 
cell vitality, which induces or co-operates to induce other affections. The 
history of disease and clinical observation tend in some degree to sustain this 
inference. Admitting the truth of these views, it cannot be said, however, that 
the disease-producing effects of vaccinia inoculation outweigh its protective 
value. 

Diagnosis. — The immediate recognition of drug eruptions from their 
objective features may be exceedingly difficult and sometimes impossible, 
especially when they simulate the exanthemata, as is often the case. The 
absence of prodromic and other constitutional symptoms, or if such are 
present, a lack of uniformity, or order of sequence, will aid the diagnosis. 
For instance, the scarlatiniform eruptions of belladonna, chloral, quinine, etc., 
occur without prodromal symptoms, suddenly appearing without high tem- 
perature, and rapidly subsiding when the drug is suspended. The morbilli- 
form drug eruptions may be distinguished from measles by the absence of 
the prodromic coryza, the continued fever with the eruption, and other symp- 
toms of the latter disease. 

The papular and pustular drug eruptions, particularly of bromine and 
iodine, might be mistaken for acne, variola and syphilis. The location of acne, 
age of occurrence, associated comedones and chronic character will usually 
settle the identity of that disease. When the iodic lesions are umbilicated the 
objective resemblance to small-pox eruption may be close, but the absence of 
fever and the more diagnostic constitutional symptoms of variola, together 
with a slower course, would serve to exclude the latter. Both bromine and 
iodine eruptions have been mistaken and treated for syphilis. A history of 
the latter and other lesions or signs of its existence can nearly always be found, 
and information as to whether these or other drugs have been taken can be 
obtained. In a case of doubt as to the nature of an eruption, it is well to 
inquire what, if any, drugs or medicines have been used. When some drugs 
have been given in full doses or for some time, they may be detected in the 
secretions and exhalations. Turpentine and other essential oils impart to 
the urine their characteristic odor; balsams administered internally may be 
often recognized in a patient's breath. Vaccination eruptions may be usually de- 
termined by careful attention to the history of occurrence. 

Treatment. — A discontinuance of the causal drug or medicine is alone 
needed to insure rapid recovery in the great majority of cases. Occasionally 
the administration of an antidotal drug in small doses will hasten recovery. 
Local protective measures may be required where open lesions exist, to pre- 
vent possible external infection ; or soothing applications to relieve uncom- 



152 DERMATITIS VENENATA 

fortable irritations. The latter will, however, quickly subside, as a rule, 
under the influence of a drug antidote. The latter can be found in most 
works on materia medica. For vaccination eruptions see indications for Apis, 
Crotal., Fer. phos., Kali mur., K. phos., Sil., Sul., Thuja. 



DERMATITIS VENENATA 

inflammations of the skin may follow from the external effects of a 
large number of substances in the vegetable, animal or mineral kingdoms; 
and show forth in erythema, papules, wheals, vesicles, bulla?, pustules, or 
gangrene, depending on the susceptibility of the individual, the nature of the 
irritant, and the length of contact. Besides idiosyncrasy, certain diatheses, 
such as the catarrhal, gouty and rheumatic, render persons more sensitive to 
such irritants. 

Common domestic applications of mustard, arnica, turpentine, etc., may 
give rise to considerable dermatitis. Several cases of arnica eruption have 
come under the author's observation, presenting the objective and subjective 
symptoms of papular eczema, though the papules were larger than in the latter 
disease, and there was little tendency to vesiculation. Primula obconica, 
now frequently kept in conservatories, will produce in the sensitive a more 
typical eczematous dermatitis. The same is true in a greater degree of in- 
tensity, from the varieties of rhus (B. toxicodendron, E. venenata, B. diver- 
siloba, E. vernix). Some persons can handle these plants with impunity; 
others are susceptible to its presence in a room, in burning wood, in hand- 
ling perfectly dry sticks or Chinese lacquer work, the dry varnish of which con- 
tains rhus vernix. In Japan, it is said, some persons cannot pass varnish shops 
in which this form of rhus is used without feeling its effects. The. rhus 
dermatitis is characterized by deep redness and frequently swelling and 
oedema of the skin, with the formation of papules, vesicles, and sometimes 
blebs on the surface. Fig. 43 shows nearly all the lesions of an ordinary case 
of rhus dermatitis — swelling, papules, vesicles and bullae between the first 
and second fingers. This is the most frequent location of rhus poisoning, often-, 
however, spreading up the arm. It is not uncommon on the face, where it may 
resemble erysipelas in appearance. It is usually transferred to the genitals 
by the hands. In severe cases, the poisonous principle (toxicodendric acid) 
is probably absorbed into the system and eruptions result therefrom on distant 
portions of the skin, as the drug taken internally causes like symptoms. 

The Virginia creeper, nasturtium, the nettle, the smartweed, cowhage. etc.. 
in all about sixty of our native plants possess irritant properties. 

Aniline dyes, supposed to contain arsenic, may cause dermatitis in not 
only those who work at their manufacture and on clothing colored by them, 
but also the wearers of such clothing in contact with the skin. The lesions 
are usually pruritic papules, in severe cases going on to vesiculation. pustula- 
tion, etc. Some kinds of caterpillars, in contact with the skin, cause marked 




Fig. 43.— DERMATITIS VENENATA 

ERYTHEMATOUS, PAPULAR, VESICULAR, BULLOUS LESIONS AND INFILTRATION OF THE 
SKIN OF HANDS AND WRISTS FROM IVY POISONING 

The patient is a young man. Attack characterized by rapid development, 
sharp pricking sensations and great tenderness, the latter somewhat relieved by 
applications of hot water. Under use of hepar sulph., sixth decimal, the inflamma- 
tion ran a short course. 







Fig. 44.— TRADE ERUPTION 

CHRONIC, MACULAR VARIETY, FROM WORKING IN AXTIMOXY AND LEAD 

Patient, a robust American man of sixty years. For forty years has worked as 
an engraver or in the antimony and lead trades. About ten years ago a single dark- 
brown spot appeared on the hand. Since that many new ones have developed, until 
gradually the right appears as in the photograph; there are a few faint ones on the 
left hand; they do not extend up the arm further than represented. For the last 
thirty years the palm of the right hand has been reddened and given to desquama- 
tion every year; this condition the patient believes is due to the potash that he 
handles. The spots are deep-seated, non-inflammatory, brownish-black, rounded 
and discrete. Under sepia, third centesimal, the inflammation and desquamation 
of the right palm have disappeared permanently, and the color of the macules has 
appreciably lightened. 




DERMATITIS VENENATA 153 

irritations.- The short barbed hairs of the brown-tail moth cause an eruption 
as I he result of mechanical irritation. It is supposed thai these hairs become 
lodged in the underclothing while hanging out of doors, because the exposed 
portions of the body are seldom attacked. This dermatitis was epidemic in 
the Medford district of Massachusetts during the summer months of 1904. 
The attendant pruritus causes mult i form lesions and consequent nervous strain. 

Eczematous eruptions may be induced by jelly fish and other water animals, 
the secretions of insects, as in the sting of bees, wasps, fleas, mosquitoes, etc. 
Pathological or decomposing secretions or discharges from animals or man, 
coming in contact with the skin, may cause a dermatitis. Many medicinal 
substances, such as cantharides, croton oil, ether, chloroform, tarry compounds, 
formalin, resorcin, mercurial preparations, strong acids, caustics and alkalies 
give rise to irritations of a varying intensity. 

Treatment. — Removal of the cause or future avoidance of it, should be 
the first step taken in the treatment of all forms of dermatitis venenata. Local 
treatment is the same as given for acute eczema. 

The eruption caused by the poison-ivy is an American disease almost exclu- 
sively, and as such its treatment should be well understood. Locally, protec- 
tion is necessary, and often cooling lotions, agreeable. Mild cases, however, 
do not need local treatment ; more severe types call for the application of wet 
dressings of saturated solutions of sodium hyposulphite or boric acid; sue. 
calendula, ten to twenty-five per cent. ; or electrozone one part to two parts of 
distilled water. Carron oil or some bland oil may be found an agreeable dress- 
ing. Ichthyol in fifty per cent, solution may be painted over the affected 
parts, or if the area involved is small, collodion may be applied. Before apply- 
ing these dressings, it is often wise to open the vesicles or blebs. 

For the types of dermatitis venenata, caused by the brown-tail moth, the 
editor has used with success an ointment containing sulphur, ten to twenty 
per cent, with resorcin, two to five per cent. 

For remedies, see Arnica, Cantharis, Graphites, Hepar Sulp., Rhus Tox., 
Rhus Yen. and Sulphur. 

Feigned eruptions (Dermatitis artificialis). — Many substances named and 
unnamed have been used by malingerers in attempts to simulate the eruptions 
of skin diseases for some ulterior purpose (as sympathy, assistance or escape 
from duty, etc.), by hysterical persons, beggars, soldiers, sailors, prisoners or 
servants. The diseases most often simulated are such as can be produced 
easily or without prolonged effort, like erythema, pigmentations, sycosis, ecze- 
ma, pemphigus and ulcers. 

Thus mustard, capsicum, turpentine, cantharides and numerous other irri- 
tants may be used to simulate erythema ; black-lead, indigo and soot, alone or 
mixed with some powder and applied to resemble chromidrosis ; applications 
of oil or fat scented with decayed cheese or asafoetida to simulate bromidrosis. 
Local applications of tartrate of antimony, oil of tar and croton oil have been 
used to simulate sycosis and other pustular affections; thapsia to imitate ery- 
sipelas; nitric acid to produce a likeness to favus cups, pemphigus blebs, or 



154 DERMATITIS VENENATA 

ulcers of the skin, caustic potash, clematis, cantharides, etc., to produce ulcers ; 
foreign substances introduced into the skin to cause abscess. Tearing and 
linear scratching of the skin with needles has been done to imitate scabies, and 
pulling out the hair in spots to simulate alopecia areata. 

Diagnosis. — The recognition of feigned skin diseases will sometimes be 
difficult on first inspection. Certain features, however, will awaken suspicions. 
In a general way there may be an absence of the local or constitutional symp- 
toms of any known cutaneous disease. The locations will very likely be within 
easy reach of the right hand, or, if the individual be left-handed, on parts 
readily accessible to that hand ; the lesion will probably lack symmetry, both in 
distribution and outline, single rather than multiple and sharply defined. 
If a liquid has been employed, it may show its accidental effects from a drop 
or two running down the surface, or by similar drop marks or stains on near, 
or distant portions of the skin, fingers or clothing. When recently used the 
odor pJLa substance like turpentine may sometimes be detected. 

The author has seen one case of perpetuated eruption where the odor of 
carbolic acid was apparent. Where sustained eruptions are suspected of being 
produced artificially, they can be hermetically dressed and the patient watched. 
The discovery of a motive for deception on the part of the patient, or of some 
of the substance applied, helps to corroborate other actual or inferential evi- 
dences of fraud. 

When the physician is satisfied as to the nature of the imposition, it will 
be wiser to keep such conclusions to himself, unless marked injustice is being 
done; and allow the patient to recover under preventive or non-medicinal treat- 
ment, rather than to cause mental distress to patient and friends, and perhaps 
his own embarrassment, by an announcement of his opinion, even if capable 
of reasonable proof. 

Trade eruptions. — Of the lesions of the skin due to occupation some might 
be included under dermatitis traumatica. In nearly all these cases the skin 
is primarily delicate in structure and sensitive to irritants, or the catarrhal 
diathesis exists to a degree which makes such individuals very liable to eczem- 
atous types of inflammation; other persons with less vulnerable skins remain 
unaffected by the same irritants of occupation. All effects on the skin of 
occupations are not inflammatory. The staining of the skin experienced by 
habitual workers on silver (argyria) has already been mentioned, and the cal- 
losities from hard manual labor are well known. 

Arsenic used in the manufacture of artificial flowers, boxes, paper, dyes, 
etc., may cause local erythema, vesicles, pustules, and sometimes oedema, ulcers 
or gangrene. Workers in the manufacture of bichromate of potash or its use 
by photograph reproducers, polishers, etc., may cause squamous, papular or 
pustular inflammation of the palms, or intense inflammation of other parts 
with papules, pustules and destructive ulcers. 

Mercury used in making mirrors, etc., may cause destructive inflamma- 
tions of the skin, but like effects follow from its over use externally or inter- 
nally (see drug eruptions). Daily handling of flour by millers, bakers or 



DERMATITIS VENENATA 



1.,, 



grocers may excite a dermatitis; the same is true of cement, mortar, strong 
soaps, etc., used by masons, bricklayers, laundresses and other laborers. The 
modern surgeon whose hands are frequently brought in contact with strong 
antiseptic solutions such as the bichloride of mercury, lysol and carbolic acid, 
sometimes experiences one of the "professional dermatoses," and, like the 
artisan, cannot always avoid the causes. Formalin, now that it is used extensive- 
ly in the arts and sciences, is often noted as a cause of dermatitis of varying 
intensity. 

Borax and Bovista may be considered as remedies in conjunction with me- 
chanical protection when the cause cannot be altogether removed. In extreme 
cases a change of occupation is imperative. 



156 ECZEMA 



CLASS III.-DIATHETIC AFFECTIONS 

In this class are grouped cutaneous affections which manifest more or 
less persistent proclivity to definite types of disease, hereditary or acquired. 
It is not assumed that direct causes do not operate to produce this group of 
eruptive disorders, but whatever their source, in nearly all the proclivity is too 
apparent to be denied. 



ECZEMA (Tetter) 

Definition. — An acute, or more often chronic, non-contagious inflam- 
mation-of the skin, attended with severe itching, catarrhal exudations and 
characterized by multiform lesions, in the same or different cases, of ery- 
thema, papules, vesicles, pustules, fissures, scales, crusts, etc. 

Eczema is perhaps the most common of all cutaneous diseases, certainly 
the most frequently seen by the general practitioner or specialist, which sta- 
tistics show as averaging nearly one out of every three cases coming under the 
observation of the latter in this country. Very likely the habit of the sufferers 
from chronic eczema of seeking one after another specialist for relief may some- 
what unduly swell the relative proportion. 

Uninfluenced by local irritation, the disease is in some degree symmetrical 
in development, though often far from uniform in its limits of distribution on 
the two sides, especially in the so-called neurotic eczemas. 

The terms acute, subacute and chronic cannot be used with much accuracy 
in reference to eczema. It may run an acute (short) or subacute (longer) 
course, and be either in intensity. Lasting longer than a few weeks, it is con- 
sidered chronic. The primary forms— erythematous, vesicular, papular and 
pustular — are commonly acute in their onset, though indefinite in duration. 
Whether the course be short or long, or merge into secondary or chronic forms, 
there may occur at various times acute or subacute exacerbations in the in- 
flammatory process. Neither does a primary form always preserve its identity 
throughout its duration; lesions of other varieties may more or less change 
its clinical appearance at one or many periods of its course. A single form of 
eruption may remain the same throughout an attack of eczema, an attack may 
be limited to certain regions; but two or more forms may exist at the same 
time associated together, or on different parts of the surface, and each pursue 
a different course, in a measure, perhaps, conforming to certain tendencies 
of location and the predominating kind of lesion. Hence, while it has been 
found impossible to describe eczema in a comprehensive way under one head, 
or in absolute divisions, the kind of prevailing lesion, and the location have 
been naturally selected as a basis for studying this polymorphous disease. 

Eczema erythematosum. — This is the least common of the primary forms, 



ECZEMA 157 

and occurs most often on the face, sometimes on the palms, soles and genital 
regions. It begins with red patches, which may remain isolated, or coalesce, 
and rapidly cover the whole surface of the face, sometimes spreading down over 
the neck. The inflamed skin presents a swollen, even cedematous appearance 
about the eyes; it is rough and slightly scaly; cracks may form and oozing 
occur therefrom or vesicles may appear on the surface. Again the scaliness 
may go on, gradually increasing in quantity until it is transformed into 
eczema squamosum or exfoliativum. Occasionally the eruption remains in 
well or ill defined patches throughout its course, and is then eczema circum- 
scriptum. Beginning on opposing surfaces, as under the breasts of women, 
and between the genital folds, it gives rise to a mucif orm secretion and becomes 
an eczema intertrigo. Erythematous eczema may be associated with other 
forms in a greater or less degree, more especially at the border of patches 
of inflammation. Eczema erythematosum may be arrested at any point in its 
course after a short or longer duration; frequently it temporarily nearly or 
quite disappears, to perhaps return with renewed intensity in a short time. 
Thus it may persist for weeks, months or years with varying intensity. It 
is always attended with itching and burning, at times of an aggravating 
character, and is nearly always worse from marked changes of temperature, 
winds, etc. 

Eczema vesiculosum. — This is the most typical of the catarrhal inflam- 
mations of the skin, and is also one of the most common. It begins ordinarily 
with sensations of itching and burning, followed by a diffused local erythema, 
on which, in a few hours, minute, clear, closely aggregated vesicles appear; 
these may enlarge in size, sometimes coalesce, rupture spontaneously or other- 
wise, and discharge a sticky serum which stains and stiffens linen brought in 
contact with it. With rupture of the vesicles, the subjective itching, etc., is 
somewhat relieved, but is worse when new vesicles are forming and usually 
at night dixring the whole course of an attack. Within a day or two the vesicles 
may cease to appear, but unlike other vesicular affections the exudation of 
plastic serum continues from the inflamed surface and makes the "weeping" 
so characteristic of moist forms of eczema. This is increased by scratching 
or rubbing the parts. Left more undisturbed, the fluid exudation dries into 
gummy yellowish crusts, which when removed show a moist surface beneath, 
on which new crusts soon form. In favorable cases serous exudation may 
cease in a few days, the color fades, and gradually the skin resumes its normal 
appearance ; in other cases, when the fluid ceases to exude, scales take the place 
of crusts, and a squamous form of eczema may persist for a time. Or a more 
severe form may ensue, from increase of the inflammation and the discharge ; 
the skin becomes intensely red and angry, with aggravations from friction and 
scratching, and eczema rubrum (E. madidans) is established. 

In a majority of cases of vesicular eczema, however, it keeps its vesicular 
type; new vesicles appearing form from time to time, at the margin of the 
patches or recurring on former sites, confined to a certain region, perhaps, or 
gradually spreading into new territory until a large surface is involved: very 



158 ECZEMA 

rarely it may become universal. Very commonly it is generalized. When 
limited to one region it is more likely to run an acute course, ending under 
treatment in two to four weeks. Vesicles may appear during the course of other 
varieties of eczema, and with some are quite common recurrent lesions. 

Eczema papulosum (Lichen simplex). — This form of eczema occurs in 
pin-head sized papules, of a bright or dull red color, discrete, confluent or 
grouped in patches, and commonly situated on the extremities, less frequently 
on the trunk, sometimes generalized but never involving the scalp. From the 
tendency to remain papular throughout, and the frequent situation of the 
papules in the hair follicles, it was once thought to be a simple form of lichen, 
and in the grouped arrangement was termed lichen circumscriptus. 

Frequently by careful search tiny vesicles can be found at the apex of some 
of the papules; more often they are blood capped from being torn with the 
fingers to relieve the intense itching. Closely aggregated papules may become 
vesicular, or partly so, and a weeping patch result as in primary vesicular 
eczema; or again, the near together lesions may become scaly, lose in a 
measure their papular character and form a patch of eczema squamosum. The 
latter change of form is not uncommon on the back of the hands and other 
parts of the extremities during the course of a papular eczema; while at the 
same time the isolated papules may be undergoing slow resolution, and a 
more or less scaly or glossy appearance of their surface is seen. The lesions 
of this type of eczema, however, are frequently persistent, or new papules pro- 
vokingly and persistently appear as the old ones fade away. 

Eczema pustulosum (Eczema impetiginodes, etc.). — Beginning in much 
the same way as the vesicular form, with local congestion of the skin, minute 
closely aggregated pustules appear on the reddened surface. Sometimes the 
lesions are first vesicular and rapidly become pustular ; or the two lesions may 
mingle in varying proportions, presenting all degrees of vesico-pustular inflam- 
mation. When seen by the physician perhaps neither lesion may be distinct, 
or possibly they may be found at the border of a patch, yellowish or greenish 
crusts having taken the place of the primary eruption over the whole or part 
of the affected area. Underneath the crust the purulent or sero-purulent exu- 
dation goes on without definite limit, lasting from a few days to many weeks. 
On hairy surfaces, as the bearded part of the face of males, the follicles may 
become inflamed and complicate the process. Sometimes a folliculitis remains 
after the more common eczematous manifestations have subsided. In the 
strumous and cachectic the pustular lesions may be unusually abundant. Ee- 
covery from pustular eczema takes place slowly, as a rule. The inflammation 
and exudation gradually subside, crusts dry more completely and are easily 
removed or fall off, the horny epithelium is restored and finally the skin is 
left in its normal condition without blemish from the disease. 

The primary forms of eczema may pass into secondary forms either on the 
road to recovery or as a continuation of the disease. Eczema rubrum (madi- 
dans) and eczema squamosum have already been mentioned. Eczema exfoli- 
ativa and eczema fissum remain to be considered. 



W r ^^^ 




WL '■ -~^^^^^^^M 




w - ^^^^^B 


'^B 


B ■ ' ^ 


■ 






1 * ■ •> ■ 




Lai 






m- ^K J 


I jL J 





Fig. 45.— ECZEMA 

PAPULO-PUSTULAR VARIETY 

Patient is an Irishman of thirty-nine. Duration of disease, two years. Occu- 
pation of porter necessitates constant exposure to water. Papulo-pustular eruption 
on the dorsum of the hands and feet. Papules with excoriations and showing a tend- 
ency to form patches, were found in the bend of the elbow, and on the face and neck. 
Itching pronounced, and worse from scratching and from water. Cured by the local 
application of vaseline and the internal use of petroleum, sixth decimal. 




Fig. 46.— ECZEMA 

CHRONIC, PAPULAR VARIETY OP THE OUTER SURFACE OF THE ARMS 

Patient a poorly nourished girl of sixteen. Disease began eight months ago 
with a general tired feeling and local sensations of itching and burning. All symp- 
toms are worse in the forenoon and from bathing. The lesions consist of papules 
made to appear more varied in size and shape by excoriations from scratching. The 
skin is dry, red and thickened, especially near the elbow. Cured with sulphur, 
sixth decimal, followed by natrum mur., twelfth. 




Fig. 47.— ECZEMA 

CHRONIC, SUPERFICIAL, GENERALIZED, SMALL ACUMINATE, PAPULAR, DRY AND SCALY 

VARIETY 

Patient is a young woman, well nourished but of a neurotic temperament. 
Disease began fourteen months ago on the arms and legs and has gradually invaded 
every region of the skin except the palms and soles. From the first itching and 
burning have been intense, with aggravations morning, evening and at times from 
close contact of clothing. Latterly the patient has suffered from mental depression. 
The lesions consist of small pointed superficial papules, many excoriated, some scaly 
and others smooth. The surface of the extremities and trunk is firm and harsh. 
Occasionally moist patches have appeared on the neck or face and the skin of the 
latter is more tense and scaly. Considerable improvement occurred under use of 
anacardiurn, third decimal. 



ECZEMA 1 59 

Eczema exfoliativa. — This variety may be said to be either primary or 
secondary, but as it appears to be due to fluid exudation without vesiculation, 
and the same fluid discharge may continue after the exfoliation has taken 
place, it seems logical to place the special exfoliative feature as secondary or 
at least intermediate, and not primary. In this form the fluid exudation 
instead of being pushed out discretely in the shape of vesicles becomes diffused 
to a greater or less extent under the corneous layer of the epidermis, causing 
it to separate and be cast off (exfoliated). The uncovered patch of epidermis 
deprived of its outer layer is red, dry, or more often moistened with a serous, 
sero-purulent or purulent discharge. The subsequent course may be similar 
to the ordinary serous, purulent and squamous forms of eczema; the exfoliative 
feature perhaps entirely disappearing in a short time. 

Eczema fissum (E. rhagadiforme) . — In this form erythema and infiltra- 
tion of the skin are the primary steps which lead to linear separation of the 
corneous and sometimes of the mucous layer of the epidermis, known as fis- 
sures. The discharge from these eczematous cracks in the skin is usually slight 
and consequently crusting is absent. They may be quite painful, especially 
in the parts of the skin subject to pressure or tension, as on the palms and 
soles, and at the flexures and extensions over the joints. Fissures heal as the 
congestion and infiltration in the skin disappear. The mildest form of this 
variety is known as chaps or chapping. 

The clinical features of eczema are modified by locality, probably from the 
anatomical differences, exposure to changes of temperature, frictions, etc., of 
the different portions of the skin influencing the character and course of the 
eruption. The tendencies determined by location, however, are only general 
and may vary widely. Beyond implying these general probabilities of type, 
the terms employed merely indicate the limitations of the eruption. 

Eczema capitis. — On the scalp the two most common tendencies of eczema 
in infants and children are acuteness and the purulent form of exudation. The 
presence of hair prevents the ready separation of the yellow or greenish crusts, 
which accumulate with sebaceous matter and add to the already existing in- 
flammation. Among the poor and ignorant, neglect and the presence of 
pediculi in the masses of matted hair may produce a most disgusting filth 
eczema to sight and smell. In severe cases abscesses are very liable to form, 
and frequently the posterior cervical glands are found swollen, tender and 
occasionally suppurate. 

In adults eczema of the scalp is most likely to be subacute, occur in squa- 
mous patches, with little or no sign of exudation. When acute, it is apt to 
be generalized over the scalp, which is then red and exudes a serous product ; 
less often the exudation is purulent. In childhood eczema of the scalp is more 
likely to extend to the face, the younger the child. 

Eczema facei. — Eczema of the face, whether primary in occurrence or 
from the extension from the scalp, is most frequently vesicular, but may be 
purulent or exfoliative. The attendant heat and itching may lead to scratching 
and rubbing of the parts, causing an aggravated appearance, from the fresh 



160 ECZEMA 

irritation and admixture of blood with the secretions. The inflammatory pro- 
cess is liable to extend to the ears, eczema aurium, where the same forms of erup- 
tion may appear, and at the back of the ears fissures may result and complicate 
a perhaps otherwise extensive eczema of the face. In eczema involving the nos- 
trils, eczema narium, the inflammation extends to the Schneiderian membrane 
which pours out an excoriating catarrhal discharge on the inflamed area. The 
nostrils become indurated and fissured and even in children, who usually possess 
this variety, the course is often chronic. The lips may become involved {eczema 
labiorum), showing erythematous, vesicular, pustular and squamous lesions. 
The movements of mastication and talking, the tendency to lick the lips and 
the mucous discharges from the mouth, all contribute to perpetuate this type. 
When an eczema of the eyelids, eczema palpebrarum, is present, a true follicu- 
litis develops among the hairs of the eyebrows, a marginal blepharitis often 
occurs, fissures form at the commissures and a conjunctivitis may complicate. 
Vesicular and purulent types of eczema may occur on the face at any age, 
but after middle life the erythematous type only is commonly seen in this 
location. 

Eczema genitalium. — Here also the erythematous form commonly first 
appears on the scrotum or vulva. On the scrotum it may be limited to the 
lateral parts and unattended with vesicles or scales. The natural moisture 
may give a certain semblance of fluid exudation, and with the heat aggravate 
the inflammation. The whole scrotum and penis may be involved in some 
cases and some scaling or exfoliation may follow. If long continued in either 
sex, the unbearable pruritus, from which relief is sought by vigorous scratching, 
may induce more infiltration and finally result in considerable thickening of 
the skin. I have seen a few cases of acute vesico-pustular eczema of the scro- 
tum so severe as to confine the patient to bed. The burning was usually 
marked in the early stage, to which was added intolerable itching with the 
appearance of the exudation; the latter was very abundant for from four to 
seven days, then the inflammation rapidly subsided, ending in recovery in 
from ten to fourteen days in all cases save one. That one persisted for nearly 
six weeks after the most acute symptoms had subsided. 

Eczema ani. — Like eczema of the genitals, eczema about the anus begins 
in the erythematous form. The congestion is attended or soon followed by 
thickening and fissures, which may penetrate into the mucous membrane. 

Eczema palmare. — When the palms of the hands or soles of the feet are 
attacked with eczema, the erythematous type is most commonly assumed. The 
surface becomes red, shiny, irregularly thickened, dry and appears seamed 
from increases in the natural lines of the skin. Fissures are likely to form in 
the lines formed by motion and- when they penetrate inward to the corium may 
be too sensitive and painful to permit tise of the parts. Sometimes the integu- 
ment becomes densely thickened and inelastic like tanned leather without 
the presence of other lesions, eczema sclerosum. The tips and less often other 
parts of the fingers may be subject to cracks and frequently they precede those 
of the palms. The exfoliative form occasionally is seen on the palms (rarely 



ECZEMA 161 

on the soles), and the acute vesicular form may occur on these parts also. In 
the latter case, the horny layer of the epidermis covering the vesicles does not 
rupture owing to its thickness, but the vesicle remains embedded in the skin, 
and when absorption of the fluid contents takes place the corneous roof sepa- 
rates, comes away as a small scale, leaving a red spot to mark its site. The 
same sort of lesions may occur upon the thicker portions of the palmar surface 
of the fingers and pursue the same course. The nails may, be attacked by ecze- 
ma (eczema unguium) and exhibit hypertrophic and atrophic changes. See 
onychauxis and atrophia unguis. 

Eczema of the extremities is more often of the papular variety, but in the 
poorly nourished pustules may follow and become further distributed by 
auto-inoculation. Below the knee the effect of gravitation on the vascular 
supply is very likely to aggravate eczema in that location. Varicose ulcers of 
this region very often are surrounded to a greater or less extent by eczematous 
skin (eczema varicosum) . 

Eczema ruhrum may exist and prove obstinate here, and on disappearing, 
occasionally leaves considerable pigmentation. Long continued eczema of the 
legs may rarely cause a wart-like hypertrophy of the skin, eczema verrucosum. 
The favorite locations for papular lesions of the extremities are the inner sur- 
faces of the thighs, legs and forearms. 

Eczema mammae involves the nipple and breast in nursing women and 
is caused by the irritation of the infant's mouth or in consequence of a galactor- 
rhcea. It may be erythematous, vesicular, squamous or fissured in character. 
Paget' s disease, which may develop from this condition, is considered among 
the epitheliomata. 

Eczema umbilici, involving the umbilicus, is more seborrheic in character, 
and will be found under seborrhceic dermatitis. 

Eczematous folliculitis has been mentioned under pustular forms of 
eczema. It occurs chiefly on the face and may constitute one form of sycosis. 
Elsewhere it is infrequent and is never seen upon the scalp. For so-called 
eczema seborrhceicum see seborrhceic dermatitis. 

Anomalous cases of eczema have been somewhat discussed and grouped 
together as neurotic eczema, "reflex neurotic eczema," etc. Many of these 
are probably only variations from ordinary forms ; and most of the remainder 
may be excited through various reflex irritations — in the existence of a pre- 
disposition to the disease. Occasionally a pure neurotic eczema is seen occur- 
ring on extensor surfaces, often unilateral and persistent. One case has come 
under my observation apparently due to a hepatic neurosis, and cured with the 
relief of the latter. 

Parasitic eczema is always secondary when it occurs, and is probably per- 
petuated by irritation from non-pathogenic flora which have accidentally 
found lodgment in the inflamed skin. In these cases brilliant cures may be 
sometimes made with local anti-parasiticides. 

The subjective symptoms preceding and attending an attack of eczema 
wherever found are not to be overlooked in estimating its nature and tendencies. 



162 ECZEMA 

The degrees of nearly all diseases are in proportion to the extent they curtail 
the comfort and usefulness of the individual. A sufferer from, the severe 
symptoms of eczema may experience much discomfort in living, without any 
immediate prospect of dying. It is not to be forgotten, therefore, that relief 
is sometimes sought more from the tormenting sensations than from the mere 
presence of the eruption. Whatever the underlying factors may be which 
produce the eczema in each case, a true conception of it must come in most 
instances from a study of the peculiar manifestation and conditions found in 
each individual suffering with it, whether located in the skin or elsewhere. 

Etiology. — Eczema is no respecter of persons or age. It may occur in 
any condition of life, though most common in the over and under-nourished; 
also, it may develop at any age, but is most frequent in infancy and childhood, 
and the first decade of adult life. Much has been said in recent years in 
favor of eczema being almost exclusively due to external causes, some able 
observers claiming that eczema can be produced by artificial irritation of the 
skin. Yet no one has demonstrated that true eczema can be produced in a 
perfectly well person by artificial means. A dermatitis with lesions similar 
to those of eczema may be excited by local agents, but the other characteristics 
of the true disease, persistency, evolution, sensations, aggravations, etc., are 
lacking. Until lesions are considered synonymous with disease, arguments 
based on mere external likeness in lesions are of little value, and hinder rather 
than aid a better understanding of the causes of a cutaneous disease. 

The more recent claim that eczema is a parasitic disease is not supported 
by any scientific proof. The assumption rests on the fact that indefinite bac- 
teria have been found in lesions of eczema, and that some cases are benefited 
by anti-parasitic applications. These observations may be admitted as true, 
and the further one that eczema may be perpetuated by micro-organisms with- 
out any real evidence appearing to prove that they are priman r causes of the 
disease. The differences between a dermatitis caused by an external irritant 
and an eczema excited by the same irritant rest wholly in the existence of a 
predisposition in the latter disease and an absence of that predisposition in the 
former. Otherwise the two diseases would be the same, which no one pretends 
to assert. It seems apparent, then, that there are both predisposing and excit- 
ing causes of eczema. What constitutes a predisposition to eczema? Xo one 
knows positively the condition of the general system which awaits local igni- 
tion (sometimes does not) to flame forth in cutaneous inflammation. That it 
is a state akin to that in gout and rheumatism seems probable. It may, in some 
instances, be the same, for those systemic diseases and eczema seldom or never 
exist together. That it is due to one unvarying state of constitution, as the 
catarrhal or hepatic, I do not believe, because there is no definite condition of 
ill being in all cases. But that a patient with a well marked case of eczema 
is not well is equally apparent; this may be noted in the dull color of the 
skin, eyes, loss of energy, changed secretion of urine, feces, etc., one or more. 
Until we understand more fully the intricate mechanism of normal mitrition 
and elimination, and the abnormal departures therefrom, the position taken 




Fig. 48.— ECZEMA 



CHRONIC, VESICO-PUSTULAR, CRUSTED VARIETY OF BACK OF RIGHT HAND 

Patient is a girl of sixteen, otherwise in apparent health, living with her parents. 
Disease began five years ago and has been confined to the dorsal surface of right hand. 
The eruption has been several times nearly suppressed by local treatment, but soon 
after returned. An outbreak is attended with itching and soreness, aggravated by 
scratching or warmth, and somewhat relieved by bathing with cold water. Some- 
times before the onset and always with an attack a pain or soreness is felt in the 
region of the left lobe of the liver. The pustular lesions develop rapidly and form 
abundant crusts. Cured with berberis, first decimal, without local measures. 




Fig. 49.— ECZEMA 

ACUTE, SYMMETRICAL, PAPULO-YESICULO-PUSTULAR VARIETY 

Patient, an American girl of eleven years, rather poorly nourished. Lesions 
commenced as pin-point papules, which, becoming vesicular, in turn became pustular 
in about three weeks. Thick dirty yellow crusts then formed. The disease was 
limited to the posterior and internal surfaces of both arms, with isolated pustules 
about the acrominal regions. Itching was marked especially at night and during 
warm weather. Olive oil was applied every night to soften the crusts and hot water 
in the morning to remove the same. Cured with sulphur, third and sixth centesimal. 



ECZEMA 1U3 

by the more moderate of the French school, Jonathan Hutchinson, II. (i. 
J'ill'anl and others, that eczema is primarily due to some, condition of diathesis, 
is the only one which harmonizes with its clinical history, frequency of occur- 
rence and recurrence. This diathesis may be hereditary, or slowly and at 
times quickly acquired. The frequency with which the stools and urine may 
be found changed in color and in other ways in cases of eczema, would point 
to the probable defect in sifting or distribution of nutritive matter to the 
tissues, or impairment in the elimination of effete materials from the tissues 
or fluids of the body. On this basis we can readily understand why eczema 
occurs in the plethoric as well as in the anaemic. Superfluity of nutriment may 
overload function as well as comparative excess of waste impair function. 

Allowing, then, that some morbid predisposing state of the cells or tissues 
of the body exists before an outbreak of eczema occurs, and which is conven- 
iently comprehended in the term diathesis, and which may at any time reach 
the verge of active irritation of nerve structure, it may require only the opera- 
tion of an ordinary exciting cause to precipitate an eruption of the skin, which 
may continue long after the latter factor has ceased to exist. 

The exciting causes of eczema are well-nigh innumerable, and may be 
internal or external. In infancy they may arise from errors of feeding resulting 
in gastro-intestinal irritations, from normal or abnormal dental disturbances ; 
or from artificial or accidental external irritants of all sorts. To these may be 
added external irritations incident to occupations in the productive period of 
life sometimes called "trade eczemas." At all ages exposures to solar or arti- 
ficial heat, and to cold and wet, may act as exciting causes. The same is true of 
vaccination, parasitic and pruritic skin diseases, pediculosis, etc. Various dis- 
turbances in the genito-urinary sphere, especially in women, may excite attacks. 
Occasionally mental emotions precipitate an attack of eczema. Indigestion 
and constipation should not be overlooked. 

In all cases of persistent chronic eczema three sets of organs and their 
functions should always be investigated; those of assimilation including food 
supply, the liver (by examination of feces, etc.), and the kidneys by analysis 
of the urine, etc. Frequently some derangement in these organs or their 
functions will be found. Finally though the exciting causes of eczema should 
be looked for in all directions (inwardly and outwardly), in many cases no 
cause can be found, and we are compelled to assume for the time being that 
the predisposing factors are potent enough to cause an outbreak unassisted. 

Pathology. — The connecting link between the causes of eczema and its 
pathological anatomy is probably always nerve irritation (tropho-neurotic), 
resulting in a catarrhal inflammation very analogous to the catarrhs of the 
mucous membranes. 

The inflammatory process begins in the papillary portion of the corium, 
later extending into the epidermis or to the deeper parts of the corium, and in 
some cases downward to the subcutaneous layer of the skin. In the papular 
form the changes take place around the follicles, especially the hair follicles, 
the cells of the rete become separated by fluid exudation and swell up. Vesicles 



164 ECZEMA 

are formed by a further liquefaction of the cells, the contents of which unite in 
small accumulations underneath the corneous layer. A pustule is formed by 
the emigration of leucocytes into the cavity formed by the contents of the 
liquefied cells. The fluid exudation instead of forming vesicles may cause a 
separation of the horny layer from the mucous layer of the epidermis (eczema 
exfoliativa ) , and sometimes leave the latter exposed, as in eczema rubrum. In 
chronic eczema there may be considerable changes in the corium, especially 
about the blood-vessels. There may be a free proliferation of connective cells 
with thickening of the derma. An extension of inflammatory exudation into 
the subcutaneous layer between the fat cells may take place, resulting in in- 
creased density, closer attachment to the skin and sometimes lymphatic obstruc- 
tion. The papillae become enlarged, elongated and sometimes papillomatous. 
The glands of the skin may become atrophied or even destroyed from the 
pressure of the hvpertrophic parts of the corium. Squamous eczema of the 
chronic—type is characterized by increased cornification and desquamation of 
the horny layer without any marked changes in the mucous layer of the epi- 
dermis. The increased supply of pigment particles to the epithelia of the 
rete is characteristic of chronic eczema. Irritations of the nerve-endings in 
the corium and rete are responsible for the many and varied subjective sensa- 
tions experienced in eczema. 

Diagnosis. — The great majority of cases of eczema are quickly recognized 
by the experienced observer. At times a diagnosis may be difficult. The 
disease is seldom seen in its primary stage of congestion, and when observed 
presents nothing distinctive. It might be confounded with erythema simplex 
or erysipelas. TVith vesiculation it is different : the vesicles are minute in 
size and closely aggregated together, they rupture and are followed by con- 
tinuous discharge, unlike the vesicles of any other inflammatory disease, such 
as herpes and scabies. The latter are larger, more often isolated and drv up 
with or without rupture. The pustules of eczema may be mistaken for a 
pustular syphilide, impetigo contagiosa, pustular sycosis and favus of the 
scalp. The papular form for a papular syphilide, lichen ruber or lichen planus, 
and papular urticaria. The squamous form may resemble tinea circinata. 
psoriasis, and possibly on the palms a squamous syphilide. 

Erythema simplex can be distinguished from eczema by its distinctive 
hyperemia, absence of inflammation and marked sensation of itching, its 
shorter duration and less tendency to appear on the face. 

Erysipelas is attended with systemic fever, a deeper redness of the skin, 
which is shiny, smooth and has a well-defined border: if vesicles appear thev 
are larger and not especially grouped, as in eczema, and desquamation onlv 
occurs after the inflammation subsides. 

Herpes vesicles are larger, usually arranged in groups on a red base, located 
on the face or genitals and dry up without rupture. The vesicles in herpes 
genitalis may be quite small, but their other features, limited distribution and 
short course are sufficiently unlike vesicular eczema. 

Scabies is practically an eczema tous dermatitis from a definite cause, and 



ECZEMA 165 

its multiple lesions and sensation may closely resemble the vesico-pustular 
and crusting types of eczema. This form of eruption found located on the 
backs of the hands (between the fingers) and on parts frequently and easily 
touched with the hands, as the wrists, axillae, genital regions, etc., may always 
arouse a suspicion of scabies. If the pathognomonic "burrow" of scabies is 
found the suspicion is at once confirmed, but if the secondary lesions have 
blotted out the dotted burrow made by the acarus scabei there may be some 
difficulty in differentiation. A scattered eruption favors scabies, a grouped 
favors eczema. In undetermined cases, a few days of antiparasitic treatment 
would settle the diagnosis by curing scabies or conversely by aggravating 
eczema. 

Pustular syphilides of the scalp ought not to be mistaken for eczema. A 
possible syphilitic history, offensive odor, adherent crusts and superficial ulcers 
underneath, or results of ulceration (scars), and the absence of pruritus are 
all unlike eczema. 

Impetigo contagiosa eruption is sometimes very like eczema. The vesico- 
pustules of the former, however, are larger, more isolated, the crusts thicker 
and darker, and when removed the skin underneath is usually sound. Im- 
petigo contagiosa is curable in from three to ten days; eczema is more 
persistent. 

Pustular sycosis and the latter stage of follicular eczema of the beard are 
practically identical. At an early stage of eczema lesions are very likely 
to appear between the hairs, and at all stages may extend beyond the limits 
of the beard, unlike true sycosis. 

Favus of the scalp with its sulphur yellow, sometimes powdery crusts, 
usually cup-shaped at some point, has little real likeness to eczema, but is to 
be borne in mind in making a diagnosis. Microscopic examination showing 
the presence or absence of favus fungi would be decisive. 

Papular syphilides of the secondary stage rarely exist alone. They occur 
usually in characteristic groups of three or four; they are a darker red and 
larger than the eczema papule and do not itch. 

Lichen ruber papulosus might be mistaken for papular eczema, and occa- 
sionally an anomalous case of eczema with considerable keratinization may 
present a striking likeness to one stage of lichen ruber. Commonly the un- 
changing, pointed, scale-capped papules of lichen ruber are distinct enough. 
They never become vesicular or excoriated, as may happen in chronic papular 
eczema. The further evolutions (confluence, scaling, etc.) of lichen ruber are 
totally unlike eczema. 

Lichen planus papules are larger, angular, flat and purplish in color, as 
compared with the small, round, acuminate, brighter red papules of eczema. 
The excoriations and blood crusts of the latter are not present in the former. 

Urticaria papulosa lesions are never grouped as in eczema, and are of short 
duration; wheals or a history of their presence can usually be found. Urti- 
caria papulosa seldom occurs after childhood. 

Psoriasis lesions do not often closely simulate squamous eczema. Patches 



166 ECZEMA 

of psoriasis show a preference for the extensor surfaces, are sharply defined, 
more or less covered with pearly white scales, which, if forcibly removed, may 
show bleeding points. Squamous eczema shows' a preference for the flexor 
surfaces; the patches are not sharply defined, the scales are darker, more 
adherent, and when removed may expose a moist surface. There is little or no 
itching with psoriasis. 

Tinea circinata may rarely be confounded with squamous eczema. Com- 
monly its asymmetrical distribution, sharply defined margin, probable history 
of contagion, and in typical forms its outer circle of papules or vesicles and 
clear center are plainly different from eczema. When a patch of ringworm 
is uniformly covered with scales and no typical lesions are found, the micro- 
scope may be needed to settle the differential diagnosis. 

Squamous sypliilides will nearly always show other signs of syphilis, either 
past or present, in the way of scars or recent lesions, and will often give a 
history of infection. Absence of subjective sensation is a distinction from 
eczema. 

Prognosis. — Every case of pure eczema is curable under judicious and 
persistent treatment. Left alone, it tends to continue indefinitely. Its dura- 
tion under treatment depends on the acuteness of the attack, and the ease with 
which the causes can be removed if ascertained. In chronic cases where 
the proclivity is well marked, a knowledge of the peculiarities of the predis- 
posing diathesis, if obtainable, is an encouragement to successful treatment. 
It is to be remembered, however, that the skin may be left too disabled to re- 
cover unaided, even after the diathetic manifestations may have ceased. The 
more extreme changes in the skin, such as great induration, elephantiasic 
thickening, or papillary hypertrophy, may be very slow in disappearing. Still 
it must be extremely rare that all evidences of uncomplicated eczema cannot 
be made to fade away. 

Treatment.— Causal methods of treatment are first in immediate import- 
ance. If no exciting factors are apparent, they should be searched for in all 
directions, and if found, removed when possible by negative or active means. 
Causes may ramify into the physiological, pathological or therapeutical fields. 
The physician who from habit looks beyond the lesions to the primary and 
earlier sources of disease wherever located in the system, as well as into the 
external sphere, will gain the best conception of an eczema, and be able to 
formulate the wisest measures of treatment. At the same time it must not 
be forgotten that a sufferer from eczema looks for relief as well as cure. These 
ends may require the combined physiological, mechanical and pathogenetic 
methods of therapeutics, and one or more may include the causal also. Thus 
in a case depending on a retention diathesis, physiological regulation of food 
(solid and liquid), exercise, etc., possibly mechanical stimulation (hand or 
vibratory massage) of excreting organs, etc.. and the administration of a con- 
stitutional remedy may all aid in removing the causal diathesis. It would be 
impossible to indicate all the details of etiological treatment. They will 
readily suggest themselves to the well-informed general practitioner as the 



a ~> a 

» 5 * 

•-. C5 

3 C 

C >-) c 

CD M 

3 o £ 

n o 3 

ft o 

o a, a 



3 



Q O O 

O 3 O 



ii o ao 



8 ?3 



p a 
to a> 

3 



Et& & 






ft) CO p- 

3 M <B 

C+ P 

(T> (T? p 

B. w "o 

Pt 1' 

sr g 



g &s 
&> ff. w 

8 § 5 ' 
S-" S- 
s 3 a 

»- a* .2 

§<° 3 

8. D* ° 

s p a 
g. a a 

» ST rf 

p 3 S- 

■< m 2 
<t> p 3 

n> 3 
C "i "^ 

a a> -+ 

- ^ ro 
^ 5; 



. fD 

i CO ~ 

. 3 

GO - 



o 


d 


Hfa 


Cd 


Br 


SI 


5" 


a 


CO 


g 


pa 




DO 




rD 






CO 


r* 


M 


S 


Cd 


o 


O 

M 



> z 





o 


C+ 


I 


B* 


> 


CD 


33 


GO 


> 


CD 


3 




s 


O 




C 





3 2 

cc 3 



3 

s 



o 





Fig. .51.— ECZEMA 



VARIETY RUBRUM. WITH CONCOMITANT SEBORRHEA 



Patient, a man of sixty-four. General health good. Four years ago, marked 
seborrhoea of the scalp was noticed; later this became generalized, especially in the 
bearded region, axillary spaces and on legs. Three years ago the legs developed an 
eczematous type, and only after persistent treatment for two years the patient was 
discharged as cured. (Sulphur being the internal drug.) Within a few months the 
same conditions reappeared, the eczema being below the knees, while the thighs, 
axillic, face and scalp were markedly seborrhceic. Burning pains and swelling of 
the legs were noticeable after the slightest walking. Every few days the oozing 
from beneath the yellow crusts is profuse; the leg is a deep red from knee to ankle. 
Treatment was directed to absolute quiet in bed, simple diet, and the use of calcarea 
fluorata, third centesimal. Later mezereum, third centesimal, was given until the 
patient developed nephritis and died. 



ECZEMA 1,; ' 

cause or causes are ascertained in a given case. The more important point 
here is to emphasize the necessity of habitually seeking for the original and 
contributing causes, and of using logical means for their removal. Such means 
will often fall within the lines of definite methods of treatment, as before 
suggested. 

Physiological (hygienic) treatment consists in the regulation of healthful 
living as bearing upon the correction of a morbid state. Often this method 
looks beyond a temporary effect to the restoration of tissue and functional 
vitality, and consequently to cure and prevention, whether through increased 
elimination or absorption. 

The quality and quantity of food frequently needs regulation. If elimina- 
tion is defective, a more vegetable and less animal diet is advisable, with such 
fruits as are readily digested by the individual patient. Thus the function of 
the liver, intestines, kidneys, etc., are facilitated. In the author's experience 
it is quite common to find those suffering from eczema fond of meat, even 
when leading sedentary lives. Barely will it be found necessary to advise a 
more nitrogenous diet to increase assimilation of constructive material, except 
in infants and children to meet the demands of growth; and then it is usually 
a change of quality that is needed, sometimes even with nursing infants. Reg- 
ulation of the fluids drunk is often as important as attention to the more solid 
articles of diet. Less fluid is demanded with a largely vegetable than with a 
largely meat diet, but unimpeded elimination requires a sufficient daily inges- 
tion of water or watery fluids. I have often found in generalized eczema a high 
specific gravity of the urine and a history of too much abstinence from water. 
It is not alone the kidneys which suffer from want of a normal supply of water, 
but the liver, intestines and glandular structures generally as well. Habits 
of bathing may err in the direction of neglect, or occasionally in the way of 
excess. Long contact of water nearly always aggravates eczematous inflamma- 
tion, and sometimes it is wise to modify it by the addition of alcohol, salt, 
or some mild alkali, for the bath, which should be brief and the skin quickly 
dried. Bathing, however, like many useful habits, must be regulated to the 
needs of each individual. Very hot water can sometimes be employed both for 
its cleansing and therapeutic effects. Used for a few minutes as hot as can 
be borne, it often relieves irritation and has a beneficial reaction. Exercise 
is often very difficult to regulate for the eczematous. and yet it is almost a 
necessity to further the transit of materials in and through the system, whose 
retention and accumulation are believed to be a fundamental cause of eczema. 
After considerable experience, I am convinced that bodily exercise must be 
prescribed in connection with some other duty, occupation or pleasure or the 
prescription will not be taken long enough to be of special benefit. Ways will 
suggest themselves to a physician best suited to each one. Passive exercise 
is not often required, and then is easily regulated by methods of rubbing, 
manipulation, etc. 

Fresh air and ventilation, especially of sleeping rooms, sometimes demand 
attention. There is no question but what sewer gas or coal gas and the 



168 ECZEMA 

accumulated emanations from the body aggravate or even produce inflamma- 
tions of the skin, as well as cause other diseases. 

While occupation can seldom be absolutely changed, advice may frequently 
be given looking to the possible avoidance of the more harmful influences or 
exposures. 

Clothing worn may be too warm, too thin, or too irritating. As a rule, 
flannel should not be worn in contact with an eczematous surface ; occasionally 
it may be worn over linen or cotton, and sometimes may be tolerated next to 
the skin. The foregoing do not include all the ways of living and habits that 
may need correction. The use of stimulants, tobacco, etc., while not physiolog- 
ical primarily, may have become a fixed habit to be wisely controlled in cases 
of eczema. 

In some cases of eczema no untoward departure from physiological living 
will be found. The diathesis is hereditary or latent, the habits of life can 
be little improved upon, and if changed, result in no benefit. Such cases are 
to be cured chiefly by pathogenetic methods. 

The local treatment of eczema has in view cleanliness, the protection and 
soothing (relief of itching) of an inflamed, sometimes denuded and exposed 
surface of the skin, which might become more irritated from contact with the 
air, water, dust, frictions, alternations of temperature, parasites, etc. Simple 
mechanical protection of the surface may be given by applications of non- 
medicated ointments, oils, pastes, varnishes, bandaging, etc. When advisable, 
a non-irritating antiseptic or antiparasitic can be incorporated in some pro- 
tective preparation. There are many substances which may be used singly 
or combined to mechanically relieve surface irritation, afford protection, or 
even to produce mild antiseptic and antiparasitic effect, without (in appro- 
priate form) producing any effect on the general system or interfering with 
the action of internal remedies. On the contrary, the beneficial effect of a 
remedy is often more apparent when the local surface is freed as much as 
possible from external irritation. For a list of protective applications see 
"Principles of Treatment" in Part. I. 

The choice of different local applications may be determined by the location 
and character of the eruption. 

Eczema of the scalp. — In children with eczema of the scalp the hair should 
usually be cut short; the crusts softened with applications of fresh lard or 
oil, a close-fitting cotton cap or a handkerchief tied about the head in the shape 
of a cap, being worn for several hours. Then the crust can usually be removed 
with a coarse comb. Subsequently the whole head may be cleansed with a 
mild and moderately hot solution of borax. After immediate drying of the 
surface, some simple oil or fat should be lightly applied and a fresh cap ad- 
justed. A most elegant oily application may consist of lanolin, one part, to 
four of sweet almond oil. Olive oil, two parts, partly emulsified with lime 
water, one part, does well in some cases, but any simple fat can be used ex- 
cept the petroleum products. If the lesions are not extensive treatment can 
be carried out without cutting the hair. These applications for protecting the 



ECZEMA L69 

surface should be repeated once or twice daily, without, however, a too fre- 
quent use of the solution, perhaps every two or three days. If pediculi com- 
plicate the local disorder, antiparasitic methods should be first employed to 
remove or destroy the parasites and their ova (see pediculosis capitis) . Occasion- 
ally lathering the scalp with a mild antiseptic soap (like boric acid five per 
cent.), and washing it off with hot water, may be substituted for the solutions. 
The object, however, is not so much the complete removal of the oily applica- 
tion as it is to remove the accumulated exudations of the disease. Even wiping 
off the old application with gauze and renewing with fresh oil will often suf- 
fice for days after the first dressing. 

In the later and dryer stages, the oxide of zinc ointment, sometimes diluted 
with a fourth part of sweet almond oil, makes a good protective dressing. 

No medicinal applications should ever be applied to the scalp of a child 
suffering with eczema. Disastrous effects have followed the indiscriminate 
use of such means. Simple removal of the irritating products of inflamma- 
tion, cleanliness and mechanical protection, together with the administration 
of the indicated remedy, are not only safer, but usually more effective. 

In adults eczema of the scalp is seldom acute or gives rise to much exuda- 
tion. If not attended with much irritation or crusting, local measures are not 
essential to a cure. When needed, the hair over the patches is separated, the 
crusts or scales loosened by friction with any bland oil or fat, and after being 
washed or wiped off the following application may be rubbed on with the end 
of the finger: 

1$ Boro-glyceride (50%) 3 2. 

White wax, 

Lanolin aa 5 1. 

Fresh lard 5 lh M. 

This may be repeated once or twice daily, as required, the preliminary 
frictions with oil being omitted. Another excellent application, recommended 
by Piffard, is as follows : 

1^ Castor oil 5 J. 

Alcohol. . 5 2$. 

Eucalyptus oil 5 li- M. 

He advises the employment of a small oil-can to deposit a drop in the 
parting of the hair over the patch, which is well rubbed in with the finger; 
then another parting of the hair made and treated as before, until the whole 
patch has been covered. In this way only so much oil as is needed is used, 
and the hair away from the patch is not impregnated with it. Either of the 
foregoing can be used less and less frequently, as improvement goes on. If 
much fluid exudation is present or intervenes, the application should be dis- 
continued and protection given to the part in the manner suggested for similar 
cases in children. 

Eczema of the face in infants requires protection of the surface by simple 
ointment or Lassar's paste ;' and when severe or extensive, the wearing of a 



170 ECZEMA 

linen or cotton mask over the parts, provisional openings being made for the 
eyes, nose and mouth. After the acute symptoms have subsided weak boric 
acid ointment or oxide of zinc gives a good protective dressing. If the ears 
are affected the mask should cover them, and it is well to sterilize the surface 
of the ears with a solution of peroxide of hydrogen (16 vol., sol. 1-5) before 
applying an oleaginous protection.' When the auditory canal is involved, small 
tampons smeared with a simple ointment can be left in the canal. Eczema 
affecting the eyelids demands special care in softening and removing the 
crusts with bland oil, followed by a very light application of benzoated lard 
or resorcin, one part to one hundred of simple unguentum. When the lips 
are affected, the tendency to crack may be largely averted by frequent appli- 
cations of bland oil or cold cream, and on the outer borders small breaks in 
continuity can be touched lightly with a soft paste. If the nostrils are in- 
volved a boric acid ointment can be used to remove the crusts, or a weak citrine 
ointment^for the same purpose. Neumann employs bougies made of two 
grains of zinc oxide with sixteen grains of cocoa-butter for this condition when 
it extends well up into the nares. 

In adults acute moist eczema of the face may be treated in the same way 
as in childhood. For the more usual erythematous eczema of the face and 
neck, the substitution of alcohol for water in bathing the face, and the applica- 
tion at night (or day if convenient) of a simple ointment, is about the extent 
of useful local measures. Increased antipruritic effect can be given to oily 
applications by the addition of one to five per cent, carbolic acid. Eczema of 
the bearded part of the face may become follicular. Here the early use of a 
solution of peroxide of hydrogen is to a certain extent preventive. If pustules 
form about the hairs, the hairs should be extracted, as their loosened position 
in the follicles act as mechanical irritants. Eepeated shaving is advisable for 
men, though painful at first. Hot borax solution or dilute electrozone may 
be used in place of the peroxide if more conveniently at hand. Boric acid 
ointment can be applied at night, and if the patient needs to go about during 
the day, boric acid and starch powder, dolomol or compound stearate of zinc 
powder can be lightly dusted or rubbed over the surface. As in all eczemas 
the appropriate internal remedy is important. 

Eczema of the male genitals is most often seen in the chronic form after 
thickening of the dependent portion (scrotum) has taken place. When an 
eczema is once started here three conditions operate to perpetuate it. namely, 
warmth, moisture and dependent position. The first objects of local treatment 
should be to neutralize the effect of these causes which cannot be wholly removed. 
Careful cleansing, the application of a hygroscopic powder and the use of a 
suspensory bandage are the means to be employed. Later a protecting oint- 
ment covered with a few layers of antiseptic gauze and the supporting ban- 
dage will be serviceable. Indicated drugs will then act with greater prompt- 
ness. In old obstinate cases a lining of sheet rubber inside the bandage gives 
relief and helps reduce the thickened skin, or local pathogenetic treatment with 
tincture of iodine, soft soap, diachylon ointment or a one per cent, solution of 



ECZEMA 171 

formalin, may be cautiously used until an acute attack is worked up, followed 
by a soothing application. The patient should always be advised of this pro- 
posed course and his assent obtained if necessary. Jn acute forms rest in bed 
is sometimes essential. Occasional applications of boric acid water, as hot as 
can be borne and for only a minute at a time, followed by the boric ointment 
before mentioned, often give much local relief. If the pruritus is severe and 
not relieved by an indicated drug, three to six per cent, of carbolic acid in 
glycerine and water may suffice. Or 

1$. Pulv. calamin. preparat 5 2. 

Glycerini 5 \- 

Aq. rosse 5 1. 

Milk of magnesia q. s. 5 4. 

M. Sig. — Apply after bathing parts with hot water. 
Or 

ly. Liniment, calcis 5 4. 

Acid, hydrocyanic, dil 5 1. 

Liq. plumbi subacetat 5 2. 

Glycerini 5 2. 

Aq. rosse q. s. 5 8. 

M. Sig. — Cream, and apply on strips of soft linen. 

"When the pubic region is affected, shaving is often necessary, before lotions 
or ointments can be applied. If the penis is involved the inflammation is 
usually milder than on the scrotum, but can be treated so far as practicable 
by the same protective means. Presistent eczema of the genitals in either sex 
should lead to an examination of the urine for the presence of sugar or other 
irritating qualities of the secretion, also as to dribbling of urine from bladder 
affections, or discharges from the mucous outlets. 

Eczema of the female genitals (vulva) is seldom as severe as in males, and 
may often be relieved by internal medication alone, being more frequently re- 
flex in nature and therefore calling for treatment of other parts. Locally 
ointments should not be used. Either equal parts of alcohol and rose water, or 
weak solutions of peroxide of hydrogen, electrozone or permanganate of potash 
will be found effective and the least objectionable applications for use as needed. 
Intense pruritus may require the carbolic or calamin solutions noted above. A 
T-bandage may be useful in some cases. 

Eczema of the anus usually develops slowly, and relief is not sought for 
at the hands of a physician tmtil it entails considerable annoyance. Then the 
parts may be thickened and fissured, the fissures perhaps extending into the 
mucous membrane. In the worst form they need to be treated as other anal 
fissures. Where cracks do not exist to any extent, brief applications of very hot 
water followed by touching the parts (including depressions) with a ten vol- 
ume solution of peroxide of hydrogen, and then smearing on a simple fat, does 
much to add to the comfort. For the thick puckered eczemas with concealed 
fissures I have found no local measures so beneficial as to immediately after 
the application of the peroxide snip the edges of the fissures or the folds with 



172 ECZEMA 

fine-pointed scissors, and then pack the same with thiol, orthoform or aristol 
on absorbent cotton held in place with a T-bandage. If necessary one may 
cocainize the parts before using the scissors, but the cutting is done so quickly 
that not much pain is experienced. The procedure can be repeated every four 
or five days if needed. Internal remedies certainly have a remarkable influence 
over eczema of the anus, and hot water may only be needed locally in mild 
cases. For intense pruritis, the carbolic, calamin or hydrocyanic lotions, be- 
fore mentioned, may be used. 

Eczema of the palms and soles presents features different from other 
parts, owing to the thickness of the skin on these surfaces and their habitual 
exposure to pressure and tension. Hence excessive thickening and fissures may 
result. Too much should not be attempted locally, and reduction of the 
thickened epidermis with file, pumice stone or sand paper seems to the author 
positively harmful by exciting more subepidermic inflammation. Small promi- 
nent p'afches of corneous thickening of the soles of the feet may be shaved off 
with a knife, the fissures filled with simple ointment, and then applications 
made to the surface of a twenty-five per cent, solution of peroxide of hydrogen. 
This can be used at intervals of four or five days, a simple protective ointment be- 
ing rubbed in during the interval. A more comfortable method is to paint 
the fissures with thiol, and then apply Unna's salicylic acid plaster over all 
the thickened skin. This can be renewed every three or four days until the 
thickened epidermis has separated and comes away. Later the parts may be 
kept soft by inunctions of oil while the internal remedy is curing the actual 
disease. On the palms, owing to the frequent motion, the disease is at best 
obstinate, and the most reliance is to be placed on the internal remedy and the 
use of rubber gloves. Gentle inunction of a small amount of weak (two per 
cent.) salicylic acid ointment several times a day often works well. Unna's gela- 
tine paste is also serviceable here, as it stays in place covered with thin rubber 
tissue, and can be renewed every day or two. Cotton gloves may be worn at 
night. 

Chapping of the hands or face is really a form of dermatitis, due to wind 
or weather, and can usually be relieved by the application of vaseline, cold 
cream or some simple oil immediately after washing and upon retiring. Equal 
parts of tincture of benzoin, glycerine and alcohol may be used not only as a 
preventive but as a curative agent in mild cases. 

Eczema of the nails only needs an occasional protective application. Ole- 
ate of tin ointment in about ten per cent, strength, as recommended by Shoe- 
maker, is good and improves the appearance of the nail. The weak salicylic acid, 
before mentioned for the palms, can be used instead several times a day as con- 
venient. 

Eczema of the extremities may be acute or chronic, dry or moist. The 
strictly papular form requires no local treatment. Acute moist forms re- 
quire rest, applications of a dilute solution of peroxide of hydrogen, followed 
by sample ointment and covering with loose absorbent gauze or bandage. The 
dressing only needs renewal as the comfort of the patient demands. The ob- 



ECZEMA 178 

jects are to give as much local comfort as practicable by protecting the surface, 
without immediately checking the exudation. Chronic types of eczema of 
the arms may be occasionally treated with stronger solutions of peroxide of 
hydrogen, subsequent protection with boric acid, gomenol or calendula oint- 
ment and as many turns of a gauze bandage as needed to completely protect 
and support the parts. The bandage should be constantly worn as a rule ; but 
renewed with the whole method of dressing as often as may be required. 
Many cases of eczema of the legs can be managed in the same way as indicated 
for the arms. On the lower legs, eczema may be kept up by varicosis, and rest 
in the horizontal position is of very great assistance. In most cases, however, 
prolonged rest cannot be carried out, and support as well as protection may 
be given by a firm bandage after applications of peroxide and simple ointment. 
Several layers of sheet lint or gauze can be placed under the bandage if there 
is much exudation. Liquor caroonis detergens one to three per cent, solution, 
is a safe and useful lotion for eczemas involving large areas, especially of the 
extremities. Varicose ulcerations demand special treatment which is to be 
found under the proper heading. Internal treatment should always take cog- 
nizance of the varicose state of the skin and often the right remedy will show 
a surprisingly quick effect, even without any local attention. 

Local pathogenetic treatment of eczema is not often called for. For the 
author's views on this subject the reader is referred to the general discussion 
of therapeutic methods in Part I. 

A multitude of simple and compound preparations have been from time 
to time advised for their various effects on the inflamed skin. Many of them 
are useless, more detrimental so far as complete cure is the end sought, and a 
few may be helpful in chronic inflammations attended with more or less in- 
filtration and hypertrophy of the cutaneous tissues. Sufficiently strong ap- 
plications to a thickened part to produce a temporary (slight or severe) ag- 
gravation may be followed by a reaction which promotes resolution and leaves 
the parts, a step nearer recovery. Such effects, occasionally repeated, aid the 
internal remedy and hasten a cure in suitable cases. Thickened patches of 
eczematous skin in the flexures of the elbows, knees, and less frequently else- 
where, can be made to clear up in reasonable time in no other way. For the 
corneous thickening salicylic acid has been already named, but its action for 
that purpose is not deemed pathogenetic. 

Among semi-liquid and liquid preparations, soft potash soap or soft 
green soap alone, or with one or two parts of alcohol (tinct. of soap), serves 
the purpose very well. Either form can be applied to an indurated patch 
with friction for a few moments, and when the irritant effect is experienced, 
the part may be washed with hot water and a simple ointment applied. This 
may be repeated every three or four days, using a weaker or stronger applica- 
tion of soap as may be judged best from the first effect, until the epidermis is 
reduced in thickness. If fissures exist they may be filled with a firm ointment 
to give them partial protection from the application. A powerful and im- 
mediate pathogenetic effect may be obtained by painting over the thickened 



174 ECZEMA 

epidermis with liquor potassce. A serous exudation occurs at once, lasting a 
few minutes. Then the surface is wiped dry and any simple protecting oint- 
ment smeared over the part and covered with a bandage. This may be re- 
peated every few days as directed for use of the soft soap or tincture. Tincture 
of iodine repeatedly painted on a patch of indurated skin until evidence of 
irritation is produced is sometimes useful, or, still better in some cases, is five 
per cent, of iodine in collodion applied every other day. For small patches of 
chronic infiltration on covered parts, five to ten per cent, of chrysarobin or pyro- 
gallol in traumaticine may be found a convenient and serviceable agent painted 
on every three days. This drug should always be used cautiously and not too fre- 
quently. For the purpose intended, the above applications, judiciously em- 
ployed, are as beneficial as and more directly under the control of the practi- 
tioner than additional preparations would be. Formulas containing some form 
of mercury have been long in use and are still frequently employed. In the 
writer's experience they are only of superior usefulness in eczema which has 
become parasitic. The ammoniated mercury in five to twenty grains to the 
ounce of vaseline or the mild chloride in ten to thirty grains to the 
ounce are cleanly and serviceable applications. "While a certain absorption 
into the skin is essential for their best effect, if the surface involved is large 
care must be taken not to use them in sufficient quantity or frequency to pro- 
duce salivation. Other anti-parasitics can be substituted for the mercurials 
or alternated with them, such as iodine in collodion or tincture; beta naphthol, 
two parts, to one part of prepared chalk and twelve parts of fresh lard; and 
when there is infiltration without much exudation, salicylic acid ten grains 
to an ounce of collodion or simple ointment. It is often necessary to control the 
persistent itching present in most cases of eczema: to this end, carbolic acid, 
calamin, thymol, menthol, dilute hydrocyanic acid or orthoform may be in- 
corporated into lotion or ointment and used when necessary. Hot water 
should always be given a trial and often will provide an efficient anti-pruritic, 
especially if bicarbonate of soda, one grain to the ounce, or hyposulphite of 
soda, three grains to the ounce, be added. 

Whatever local application may be used in treating eczema, it should be 
for a definite purpose, and when that is attained a recourse to simple protec- 
tive methods will usually bring about the best results. 

Galvanism has been used with good effect in a few instances where there was 
pronounced localized induration. An impetus to recovery has been given by 
the application of the negative electrode of the galvanic battery, every three 
or four days, using two to twenty milliamperes. The static spark may be 
of similar service, but this form of electricity serves its best purpose as a 
general nerve stimulant. The high frequency currents through the vacuum 
electrodes applied at a distance of a quarter of an inch to the eczematous sur- 
face, for one to five minutes, twice a week, have afforded a safe means of 
hastening the resolution of indolent patches, causing general stimulation 
and exerting a varying amount of anti-pruritic and germicidal action. The 
editor has noted pronounced benefits following the use of the high frequency 



ECZEMA 175 

•currents in thirty-six cases of eczema (sub-acute recurrent or chronic types) 
and occasionally cures have resulted from this agency alone. Acute eczema 
docs nol call for electro-therapeutic treatment. Cautious use of the Runt- 
gen rays, exposures varying from three to ten minutes at a distance of five 
to ten inches from the tube, has given relief where all other methods have 
failed. The editor has seen the sclerotic and verrucose types of eczema yield to 
the X-rays. The unipolar X-ray tube appears to be particularly well suited 
to some stubborn eczemas especially of the hands and face. It may be applied 
for two to ten minutes daily or at longer intervals. 

Finsen and his associates do not claim that phototherapy has accom- 
plished spectacular results in eczema, and at the present time, although 
cases have been reported as cured, it can hardly be said that the method is 
superior to radiotherapy. Radium in 25,000 and 200,000 radio-activity 
has been used in treatment of ten cases of eczema by the editor, with exposures 
varying from five to forty minutes, every second, third or fourth day. Relief 
of the pruritus was accomplished in four instances, but no further results were 
noted. 

Internal pathogenetic treatment is of the greatest importance, and is 
only placed last in order in conformity with the general plan. All the types 
of cutaneous disease which are believed to depend on an underlying proclivity, 
state of constitution or diathesis call frequently for the administration of 
so-called tissue drugs, which may have a very wide range of action impossible 
to formulate into indications closely corresponding to many individual cases of 
disease. The more general scope of the remedy and some of its special peculiari- 
ties simulating the manifestations of eczema is all that is practicable within 
reasonable limits. 

The subjoined repertory may assist in selecting indicated drugs from the 
group in the therapeutic supplement of this section. 



CONDENSED REPERTORY FOR ECZEMA 

LESIONS 

Erythema (redness). — Am. carb., Bell., Benz. acid, Colch., Comocladia, Crotal., Crot. 
tig., Dulc, Hyds., Jug. tin., Kali bichrom., K. iod., Led., Lye, Merc, Mez., Nit. acid, 
Puis., Rhus tox., Sil., Thuja, Zinc. 

Papules. — Anacard., Ars. iod., Benz. acid, Bov., Bry., Carbol. acid, Caust., Clem., 
Comocl., Coni., Dulc, Fago., Graph., Hepar, Hyds., Jug. tin., Kali bichrom,. K. carb., K. 
iod., Kreso., Led., Lye, Mangan., Merc, Mez., Mur. acid, Nat. mur., Nit. acid, Nux vom., 
Olean., Pet., Puis., Rhus tox., Rumex, Sepia, Sil., Staph., Sul., Tel., Thuja, Zinc. 

Vesicles. — Bov., Bry., Cal. carb., Canth., Caust., Chel., Clem., Coni., Corn, tire, Cro- 
tal., Crot. tig., Dulc, Graph., Kali iod., Kreso., Lye, Mangan., Mere, Mez., Mur. acid, 
Nat. mur., Nit. acid, Oleand., Pet., Psor., Puis., Rhus tox., Sepia, Sil., Staph., Sul., Tel., 
Thuja, Zinc. 

Pustules. — Ant. crud., Ars. iod., Bov., Cal. carb., C. sulph., Clem., Colch., Coni., Cro- 
tal., Crot. tig., Graph., Hyds., Iris ver., Kali bichrom., K. iod., Lye, Mez., Mur. acid, 
Nat. mur., Nit. acid, Nux vom., Oleand., Pet., Psor., Puis., Rhus tox., Sil., Staph., Sul., 
Thuja, Zinc. 



176 ECZEMA 

Erythemato-vesicular. — Arnica, Rhus tox. 

Papulo-vesicular. — Arnica, Am. carb., Ars. iod., Baryta carb., Carbolic acid, Led., 
Rhus tox. 

Papulo-pustular. — Anacard., Baryta mur., Berb., Cal. fluor., Carbolic acid, Caust., 
Chel., Hepar, Kali iod., Merc, biniod., Rumex. 

Vesico-pustular. — Cal. fluor., Kali mur., K. sulph., Psor., Viola trie. 

Squamous (Scaly, dry). — Aluminia, Ars., Cal. fluor, Cup. ars., Graph., Hydrocot., 
Kali carb'., Kali phos., Kreso., Merc, Mez., Nat. mur., Rhus tox., Sul., Thuja. 

Crusted. — Cal. fluor., C. sulph., Clem., Dulc, Graph., Merc, M. biniod., Mez., Nat. 
mur., Nit. acid, Pet., Psor., Rhus tox., Sul., Viola trie 

Fissured. — Kreso., Nat. mur., Nit. acid, Pet. 

Ulcerative. — Kali bichrom., Merc, Mur. acid, Nat. mur., Nit. acid, Sil. 

Warty or fungoid. — Colch., Kali iod., Nit. acid, Staph., Thuja. 

Gangrenous. — Conium, Crotalus. 

COURSE OR TYPE 

Acute. — Am. carb., Bell., Canth., Crot. tig., Jug. cin., Rhus tox., Thuja. 

Chronic. — Alumin., Ars., A. iod., Crotal., Hydras., Hydrocot., Kali carb., K. mur. 

LOCATION 

Generalized or not characteristic. — Anacard., Ars. iod., Baryta carb., Colch., Fago., 
Lye, Psor., Puis., Rhus tox., Sil., Sul., Thuja, Zinc. 

Face, Ears and Head. — Am. carb., Ant. crud., Ars. iod., Bov., Cal. carb., C. phos., 
C. sulph., Canth., Garbol. acid, Chel., Clem., Comocl., Coni., Corn, circ, Crot. tig., Dulc, 
Graph., Hepar, Hydras., Hyperic, Iris ver., Kali carb., K. iod., Kreso., Merc, Mez., Nat. 
mur., Nux vom., Oleand., Pet., Puis., Sepia, Staph., Tell., Vinca min., Viola trie 

About Mouth or Nose. — Amt. crud., Caust., Mur. acid, Nit. acid. 

Neck and Shoulders. — Carbol. acid, Clem., Hepar, Hydras., Kali iod., Kreso., Nit. 
acid, Nux vom., Puis., Staph. 

Arms. — Arn., Dulc, Graph., Hydras., Kali iod., Mez., Nat. mur., Nux vom., Staph., Tell. 

Hands and Wrists. — Berb., Bov., Cal. carb., C. phos., Canth., Coni., Cup. ars., Dulc, 
Graph., Hydras., Hyper., Kreso., Mez., Nit. acid, Pet., Sepia. 

Breasts. — Caust., Kali carb. 

Umbilicus. — Merc, biniod. 

Trunk. — Comocl., Kali iod., Mez., Nit. acid, Nux vom. 

Genitals. — Am., Ars. iod., Benzoic acid, Canth., Chel., Coni., Croton tig., Graph., 
Hepar, Hydras., Kali iod., Merc, Staph. 

Anus. — Aloes, Berb., Cal. fluor., Merc, biniod. 

Thighs. — Hepar, Merc, Nux vom. 

Legs. — Arn., Chel., Comocl., Kali carb., Mez., Nat. mur., Rumex, Staph., Tell. 

Feet and Ankles. — Arn., Mur. acid, Nat. mur., Pet. 

Flexures or folds of skin. — Caust., Hepar., Merc, M. biniod., Nat. mur., Sepia, Zinc 

CONDITIONS AND SENSATIONS 
AGGRAVATIONS 

Evening and night. — Alum., Anacard., Ars., Cal. carb., Carb. acid, Caust., Como., 
Coni., Crot. tig., Hepar, Hyds., Kali iod., K. sulph., Kreso., Led., Lye, Merc, Mez., Nat. 
mur., Nit. acid, Pet., Ranune, Rhus, Sepia, Staph., Tell., Thuja, Viola, Zinc 

Morning and day. — Aloe, Anacard., Arn., Bary. e, Bov., Cal. carb., Chel., Como.. 
Crot. tig., Dulc, Hepar, Hyper., Lye, Nat. mur.. Nit. acid, Nux vom., ret., Sepia, Sil., 
Sul., Thuja. 



PSORIASIS 



177 



Changes of temperature. — Hell., Biy., Cal. phos., Hyds., Ranunc, Rumex. 

Cold and cold weather — Ars., Cal. carb., Ikpar. Merc, Pet., Rhus, Rumex, Tel., 
Thuja. 

Dampness and damp weather. — Aloe, Cal. fluor., Cal. phos., -Merc.. Mez.. Nit. acid, 
Rhus. 

Warm and warm weather. — Alum., Aloes, Anacard., Bell., Berb., Canth., Caust., Clem., 
Como., Dulc., Graph., Iris, Jug. cin., Kali bichrom., K. carl).. K. sulph., Led., I.yc., Merc, 
Mez., Mur. acid, Nux vom., Psor., Puis., Sul. 

Cold water, washing. — Ant. carb., Ars. iod., Bary. carb., Bov., Cal. carb., Clem., 
Coni., Crot. tig., Nat, mur., Sul., Thuja. 

Touch.— Bell., Berb.. Carb. acid, Como., Crot. tig.. Fago.. Lye, Mez., Mur. acid, Nit. 
acid, Staph. 

Open air. — Caust., Crot. tig., Kali carb., Nat. mur., Psor., Zinc. 

Scratching.— Berb., Como., Coni., Graph., Fago., Hyper., Oleand., Pet., Ranunc, 
Tel., Zinc. 

Walking. — Aloes, Berb., Iris, Jug. cin., Merc, Mez., Psor. 

Rest. — Am. carb., Bary. c, Chel., Como., Coni., Kali mur., Mur. acid, Oleand., Rhus, 
Tel., Thuja. 

Pressure. — Chel., Iris, Kali be, Kres., Mangan. 

Excessive eating. — Aloe, Am. carb., Dulc, Nux vom., Puis., Sepia, Sulphur. 

AMELIORATIONS 

Evening and night. — Hyper., Kali be, Lye, Nux vom. 
. Morning and day. — Merc, Psor., Sulphur. 

Cold application and bathing. — Berb., Canth., Dulc, Graph., Kali carb., Nit. acid, 
Rhus, Sepia. 

Cold weather. — Kali bichrom. 

Dry weather. — Am. carb., Dulc, Rhus. 

Warm applications. — Ars., Bry., Cal. carb., Nit. acid, Rumex, Sil., Thuja. 

Open air. — Bary. carb., Como., Kali sul., Lye, Mez., Puis., Sepia, Thuja. 

Motion or exercise. — Chel., Como., Kali phos., Rhus, Sul. 

Scratching or rubbing. — Caib. acid, Canth., Colch., Hyds., Kali iod., Kali phos., Kreso., 
Led., Lye, Mangan., Mur. acid, Nit. acid, Nux vom., Rumex, Staph., Sul., Zinc. 

Eating. — Chel. 

Pressure. — Hyper., Kali carb., Rhus, Sepia, Zinc. 

Rest. — Merc, Pso. 

Lying down. — Cal. fluor., C. phos., Canth., Puis. 



PSORIASIS 

{Lepra; Alphos; Psora.) 

Definition. — A chronic disease of the skin characterized by lesions 
primarily round in shape, dry, red, and more or less covered with yellowish, 
pearly or silvery white adherent scales, which may be abundantly shed, 
and if removed, rapidly re-form. 

Owing to its persistency and tendency to recur, psoriasis is one of the most 
common cutaneous diseases. It manifests its systemic origin by usually oc- 
curring symmetrically, and its probable connection with some derangement in 
nutrition by generally beginning on the extensor surfaces, where the circula- 
tion is less active than in many other parts of the skin. 



178 PSORIASIS 






Symptoms. — Without prodromal signs of any kind psoriasis first makes 
its appearance in pin-head sized, reddish macules which, within forty-eight 
hours, become capped with a whitish scale, psoriasis punctata. The spots 
gradually enlarge in diameter and in thickness of the scales so that when about 
one-fourth of an inch across they look like drops of mortar laid upon the 
skin, psoriasis guttata. Some or all of the patches may rapidly or slowly in- 
crease in size by peripheral growth, and when they reach the size and shape 
of familiar coins are known as psoriasis nummularis; continuing to spread 
outwardly two or more patches may coalesce forming an irregular shaped lesion, 
or resolution may occur in the centre of a patch leaving a ring-like form, 
psoriasis annulata. If two or more circinate lesions join, compound ring 
shapes are seen, and later, as the points of contact melt away, irregular lines 
are left, psoriasis figurata or gijrata. Usually these transitional forms are 
very slow in their evolution; or, again, the lesions may be arrested at any 
stage, to remain more or less stationary, or slowly, sometimes rapidly resolve. 
The individual spots may vary widely in their rate of progress, so that in 
some cases nearly all the above forms are present at the same time. Occasion- 
ally the union of patches goes on until there is a wide extent of surface in- 
volved in varied or more uniform appearance, psoriasis diffusa. Barely the 
disease may be widely generalized or pass into a pityriasis rubra, and then has 
been called psoriasis universalis. Persistent eases with more than usual thick- 
ening of the skin, sometimes fissures, heavy and more adherent scales have 
been termed psoriasis invcterata. When there is a tendency to the central 
heaping of scales, the terms psoriasis rupiodes or psoriasis ostreacea are ap- 
plied. Rarely papillary hypertrophy is noted, psoriasis verrucosa. 

The scaling, which is always a feature of psoriasis, varies in different 
cases, different spots and at different times. While the scales are adherent, they 
can be readily removed, and if of recent formation, minute bleeding points 
are apt to appear from forcible detachment. The color of the affected skin is 
at first rose or light red, usually becoming a brighter red if the progress is 
acute, and a deeper red when the lesions persist for some time. Sometimes 
in the more acute cases the scales are thin, do not accumulate, and the lesions 
especially on the extremities may present an angry, less defined appearance, 
with sometimes heat, tenderness, itching, and, if irritated, may produce a dis- 
charge altogether resembling eczema. 

In nearly all cases the eruption is dry from beginning to end, whether of 
short or long duration. Untreated the disease tends to continue, but spon- 
taneous remissions are likely to occur. Some cases go through a lifetime 
without a complete cessation of the eruption and without any special disturbance 
of the general health. Others may show temporary disturbances of nutrition 
or some constitutional defect. When the eruption disappears it may leave 
no trace behind except a temporary redness, or a more persistent discoloration 
on dependent parts, as the legs, may remain, and sometimes after treatment 
with full doses of arsenic there is pronounced pigmentation. 

Psoriasis may be limited in distribution to the extensor surfaces of the 




Fig. 52.— PSORIASIS 



CHRONIC, INVETERATE VARIETY, OF FOREARM 



Patient is a middle-aged man; occupation, carpenter. He states his father 
was subject to a similar eruption. Disease first appeared fifteen years ago, abating 
in summer for a few years; later some patches have been unaffected by changes of 
the seasons. The lesions are situated on the trunk and extremities and van- in size 
from a cherry to an orange; the larger are thickly covered with firmly attached, 
pearly white scales (removed at two points from the patch photographed, showing 
the deep red base and the bleeding points as black specks). A few lesions have 
become annular in shape. Moderate improvement occurred while the patient was 
taking hydrocotyle, third decimal. 




Fig. 53.— PSORIASIS 

ACUTE, LOCALIZED VARIETY OF THE ARM 

Patient, a woman at the menopause period; occupation, housekeeper; general 
health good. The attack began three weeks ago with heat and burning sensations and 
great intolerance to scratching or rubbing. Some relief has been obtained from warm 
applications and from exercise. Lesions consist of flat maeulo-papules, situated on a 
bright red area of skin, and partially covered with pearly white and whiter scales. Cured 
with arsenicam alb., third decimal, in gradually increased doses. 



PB0RIA8IS 17! * 

- (or only on the knees), thighs, arms (perhaps only the elbows), scalp, 
back, less commonly on other parts of the trunk, flexor aspects of the ex- 
tremities, face, and rarely on the palms and soles. Never does it develop, how- 
ever, in the two latter locations without first appearing elsewhere on the skin. 
Crocker asserts that the majority of cases of so-called palmar or plantar 
psoriasis are of syphilitic origin, or else are eczema. 

Psoriasis never attacks the mucous membranes, but may extend on to the 
glans penis. On the scrotum it may lead to considerable thickening and iissur- 
ing of the skin and a thin exudation. The nails may become affected by 
psoriasis (see onychauxis) and present nothing characteristic. Sometimes it 
begins with a patch of discoloration under the border of the nail, or underneath 
the body of the nail. There may be a slight depression of the nail only, 
or all degrees of hypertrophy may follow. The presence or history of the dis- 
ease elsewhere must usually be relied on to determine its nature. On the 
scalp the disease rarely interferes with the growth of the hair; but it is often 
noted that it will remain on the scalp for months or years before becoming gener- 
alized. When it advances to the hair border a red line or strip may be seen 
which resembles eczema, but it is never moist. 

Psoriasis is a disease of all ages and conditions of life. It usually be- 
gins primarily in early life,, authorities differing as to the most common 
age. Bulkley (Transactions of the Medical Society of the State of Xew 
York, 1895) gives as the result of an analysis of 366 cases in private prac- 
tice, fifteen to twenty years of age as the period when the largest number 
(over twenty per cent.) of cases first appeared, while a majority (fifty-five 
per cent.) were found to have had the eruption first between ten and twenty-five 
years of age. Greenough (Transactions Am. Dermatological Assoc, 1885) 
makes the most common age of first occurrence between ten and fifteen, and 
Xeumann, as quoted by Bulkley, places the time of first appearance at about the 
sixth year of life. A number of cases have been reported as occurring in the 
first year of life, the editor has treated one case appearing before the fourth 
month, and Wilson mentions a case at eighty-five. It is not extremely rare after 
fifty. As compared with other common diseases of the skin, it stands about 
fourth in order of frequency (two to three per cent, of all skin cases). 

It remains to be noted that psoriasis may be modified in appearance by 
various influences. Thus, in acute fevers, especially the exanthemata, the 
eruption is likely to disappear, to return again with the restoration of the 
usual health. Eczema and syphilis usually have no effect on psoriasis; either 
disease may exist side by side without modifying each other. On the other 
hand, scrofula, gout, parturition and lactation tend to aggravate the disease in 
one way or another. A change from the usual appearance of psoriasis may be due 
to previous treatment to remove the scales: in cases attended with much pruri- 
tis frequent excoriations may result in pus inoculation and eethymatous and 
other lesions arise therefrom. Even without arsenic, pigmentations may rarely 
attend or follow psoriasis: still more rarely atrophy of pigment, real or ap- 
parent from increase of color about the site of a patch, as well as superficial 
scarring may be a sequence. 



180 PSORIASIS 

Etiology. — The natural and clinical behavior of psoriasis indicates that 
it may be due to some systemic cause or causes not incompatible with general 
vigor. The presence or predominance of an element in the circulation or 
tissues sufficient to irritate the nerve structures which control the nutrition of 
the skin is the most plausible explanation of its causal operation in the absence 
of scientific proof. In other words, the essential causes are internal and 
constitutional, and when the predisposition is thus established the external 
evidences of the disease may appear with or without the aid of an exciting 
factor. 

It has been claimed that syphilis is a remote cause of psoriasis; also, that 
rheumatism, gout, struma, tuberculosis stand in etiological relation to it, 
but scientific proof is wanting, although the editor has noted the presence 
of the uric acid diathesis in fifty per cent, of the cases of psoriasis inveterata. 
Heredity seems to be an important factor as attested by the clinical records 
of the last two hundred cases treated by the author and editor, in which about 
twenty"per cent, of the cases give some variety of hereditary influence. E. 
Wilson gives thirty per cent, as the proportion and Bulkley's report shows 
the existence of a probable hereditary influence in about fifteen per cent., 
though the history of occurrences of the disease in children and grandchildren 
(posterior heredity) and in brothers, sisters and further removed relations 
(collateral heredity), if admitted, would greatly increase the proportion. 
This, however, is not exceptional to psoriasis. The disease often begins in 
childhood, but no child is known to have been born psoriatic. "While heredi- 
tary tendency (as in most diatheses) cannot be denied as existing in some cases, 
it is probably much less frequent in psoriasis than in some other diseases, 
such as gout, rheumatism and syphilis. Modern views as to the nature and 
origin of tuberculosis and leprosy would suggests possible parasitic etiology 
in cases occurring in the same family, quite as reasonable as the theory of 
heredity. Although attempts at direct inoculation have failed, Destot inocu- 
lated himself from an infant with vaccinal psoriasis, and Lassar produced a 
skin disease in rabbits by rubbing into their bodies, scales, blood and lymph 
removed from psoriatic patches of a man. 

Rare instances have occurred where psoriasis followed vaccination, tattooing 
and other excoriations of the skin, and these would point to the fact that the 
disease is an acquired one. The biborate of soda, given internally, and injec- 
tions of tuberculin have also produced psoriasis. The often noted occurrence 
of psoriasis in gouty families has led some clinicians to believe that the two 
diseases were etiologically related. The same views are held to some extent 
as regards rheumatism. Although my personal experience does not support 
this view so far as based on related attacks, on the other hand, evidences of a 
similar retention in the system, or excess of waste or other products in the 
secretions, have been found in a large per cent, of cases. The urine is often 
hyperacid and of a higher specific gravity than the average, due to phosphates, 
urates, etc. The stools are not infrequently lighter than normal in color, and 
constipation or other signs of defective hepatic fimetion is not uncommon. 




Fig. 54— PSORIASIS 

GUTTATA AND NUMMULATA VARIETY 

Patient, a Dane, of twenty-seven. By occupation, a seaman. Duration of 
disease, thirteen years. Generalized, discrete lesions with pearly scales. More 
prominent on the hands, arms and back. Always aggravated in the summer. 
Started in the scalp. Cured in three months by Phytolacca, second decimal, with- 
out local treatment. 




Fig. 55.— PSORIASIS 

NUMMTILATA VARIETY 

Patient, a girl of seventeen. Duration of the disease, ten years. 
More pronDunced on the extensor surfaces of the arms and legs. Scales 
are yellowish and greasy, and itch cDnsiderably, due to the accom- 
panying seborrhceic dermatitis. Improvement has occurred under 
the use of natrum sulph., sixth centesimal. 



PSORIASIS 181 

Notwithstanding the apparent robust health of many sufferers from the 
disease and the absence of any special complaint on their part, I have seldom 
seen a case where some departure from even their personal standard of health 
could not be found on careful examination. In this way a certain basis for 
treatment can usually be established. 

Whatever the dynamic origin of psoriasis may be, its ultimate development 
seems uninfluenced to any extent by age, sex, rank or occupation. The general 
run of cases are worse in winter. Granting the predisposition, many of the 
exciting causes noted in eczema may likewise determine an onset of psoriasis. 
External frictions, excoriations, etc., may fix the earlier site of lesions. Grief, 
fear, mental strain and other nervo-mental influences may precipitate an 
attack. 

Pathology. — Many different opinions are held as to the nature of the 
conditions which cause the histo-pathological changes in psoriasis. Some 
claim that they are parasitic, others that they are neuropathic. The most 
plausible theory is that the disease is due to an undiscovered parasite "im- 
planted on susceptible soil." It is fairly well agreed that psoriasis begins as 
a non-inflammatory hyperplasia and multiplication of the cells of the mucous 
layer of the epidermis, producing downward growth of the interpapillary pro- 
cesses and apparent elongation of the papillae, followed by dilatation of the 
blood-vessels of the papillary layer of the corium, serous transudation and 
moderate cell infiltration around the vessels. The changes in the cells of the 
horny layer of the epidermis may be due to premature conversion of the rete 
cells or to anomalous keratinization. In advanced cases, vascular dilatation 
may extend into the deeper parts of the derma, and the infiltration, together 
with the changes in the epidermis, elevate the lesions above the level of the 
skin. The silvery-white color of the scales is caused by the presence of air 
between the cells forming the scales. 

Diagnosis. — The presence of some of the characteristic features of psori- 
asis — location of lesions on extensor surfaces (often on knees and elbows), 
their symmetrical distribution, absence of moisture and marked subjective 
sensations, pearly-white adherent scales, and the red, often bleeding points on 
removal of the scales — readily distinguish the disease from all others. The 
method of evolution and long duration, when known, may be of assistance. 
It is only in the atypical cases that doubt may arise. 

Eczema squamosum may resemble psoriasis. Generally some history of 
moisture, the ill-defined border of an eczema patch (thickest in the centre), 
its darker and less abundant scales, location in the flexures of the joints or on 
the flexor surfaces, and the presence of marked pruritis will clearly establish 
the existence of eczema. Sometimes the two diseases exist together. Both 
may affect the nails; eczema most often attacks all, psoriasis one or more, 
never all at once. 

Seborrhcea of the scalp is generally more diffused than psoriasis. If the 
latter extends beyond the hair line, it shows its characteristic appearance, and 
its lesions or a history of them on its favorite locations can usually be found. 



182 PSORIASIS 

The scales of seborrhcea are dirty and fatty, and if removed show a pale 
surface, rather than a red or bleeding area, as in psoriasis. 

Seborrheic dermatitis of the non-hairy parts may closely resemble psoriasis 
in shape of lesions and the readiness with which they can be made to bleed, 
but the scales of the former are not pearly or silvery white, rather they are 
greasy and tend to form into crusts, and the affected skin is generally a yellow- 
ish-red. It seldom occurs in the favorite locations of psoriasis. In doubtful 
cases, a history of the origin of the eruption and its evolution will clearly 
establish its nature. 

The lesions of trichophytosis may be distinguished from psoriasis by a his- 
tory of contagion, asymmetrical location, elevated and at first papular margin 
and when on the scalp by the short, stubby hairs. Its scales are usually scanty 
and under the microscope will show the presence of the fungi of ringworm. 

Lupus erythematosus seldom simulates psoriasis. It is often situated on 
the faee> an uncommon site of psoriasis. Occurs generally first in middle 
life instead of before, as is the rule with the latter. Its scales are scanty, very 
adherent and when removed often show the patulous opening of the sebaceous 
follicle from which a pellicle of the scale has been torn. On the scalp lupus 
destroys the hair, and here and on other parts in its evolution leaves sores, 
neither of which effects follow psoriasis. 

Lichen planus and rubra eruptions very rarely may look like psoriasis 
when the former has formed patches or become generalized. Lichen plan us 
begins as flat, smooth, shining, angular papules which may be aggregated 
together and new lesions spring up between the early papules, thus forming 
infiltration, over which there may be a scant scaliness. Psoriasis begins as a 
minute spot which enlarges at the periphery, alone forming a roundish patch, 
or in union with similar patches forms larger and less regular patches over 
which there is usually abundant scaling. Moreover, the latter selects the 
extensor surfaces and lichen, as a rule, the flexor, especially at the wrists and 
sides of the knees. The bluish-red color of lichen planus contrasts with the 
brighter red of psoriasis, and the stains left by the former are rarely seen after 
the latter except as an effect of treatment. The acuminate papules of lichen 
ruber begin on the trunk and the infiltrations are formed in the same way 
as lichen planus. When generalized the infiltration of the skin is much greater 
than in like cases of psoriasis, and the scaliness much less. 

Pityriasis rubra rapidly spreads all over the surface of the skin and the 
scales are thin, paper}^, easily detached, do not fully cover the reddened skin 
and are never piled up in crusts. Any similar picture from psoriasis would 
.be months or years in developing. 

The scaly syphilides may be easily mistaken for psoriasis in the absence 
of a definite history of syphilitic infection. Syphilis of the skin, like eczema, 
is a polymorphous affection, and nearly always other than scaly patches can be 
found or evidence of their previous existence learned. Signs of the disease 
on the mucous surfaces where psoriasis is never seen may frequently be 
discovered. Syphilis seldom occurs on the elbows or knees. The lesions- 



PSORIASIS l *' d 

of the secondary form arc rarely large and do not tend to spread peripherally; 
the scales are of a dirty gray color and not abundant or freely shed. After a 
few days' duration, the brownish-red color of syphilitic lesions are character- 
istic, as are also the fawn-colored pigmentation left after the eruption sub- 
sides. The constitutional symptoms of syphilis, bone pains, etc., if noted, may 
aid the diagnosis. The scaly lesions of tertiary syphilis are usually few in 
number and not symmetrically distributed. The edge of a patch is often 
elevated, so that the centre appears depressed, and with or without ulceration, 
Bears and deep stains commonly follow. Still, the resemblance to psoriasis 
is so close in some cases that careful investigation of the history, etc., will 
be necessary to remove all doubt. 

Prouxo.-ms. — Many cases of psoriasis can be cured by carefully selected 
treatment. Some in a few months when the indications are clear and the 
disease has not been of long duration. Others may require years of attention 
before the liability to near recurrence can be eradicated. A large proportion 
of the latter, otherwise enjoying average health, will not continue a systemic 
remedial course sufficiently long to insure good results. Most of the cases 
which have been under my observation for several years of treatment have 
fully recovered, or at least ceased to have annual or other recurrence. The his- 
torically bad prognosis of psoriasis is no longer justified; rather, in general, it 
may be said at least to be hopeful as to permanent cure as well as for temporary 
relief. 

Treatment. — Every case of psoriasis having been carefully individualized, 
treatment by whatever method should be directed to the correction of the 
underlying systemic cause, however slight that may appear. All that is com- 
prehended under personal hygienic living may be regulated in some degree. 
If radical changes are needed, they can be made gradually by looping off here 
and adding there; perhaps in cutting down diet and adding physical exercise 
to help correct sub-oxidation so often existing in diathetic affections. In 
youth regulation of diet may be only acquired, usually by increase of vegetable 
and lessening of animal food. Barely more nitrogenous food may be needed 
during the formative age, but even in cases exhibiting some debility it is sel- 
dom that any part of it can be attributed to abstinence from animal food. In 
early adult life and after, the majority of psoriatics indulge in too much nitro- 
genous food, and often in a too liberal diet altogether. Hyperacid states result 
especially in those leading sedentary lives. A gradual or immediate change 
to a largely vegetable dietary (favoring alkalinity), though perhaps at first 
not well borne, is ultimately of much benefit. In the vigorous often the omis- 
sion of one regular meal out of the day works well. I have seen the good 
effects from foregoing breakfast altogether or cutting it down to very moderate 
proportions, at the same time increasing the quantity of fluid drank, preferably a 
pure water, but the tastes of patients cannot be altogether disregarded if we 
expect directions to be carried out. A liberal supply of oxygen by systematic 
ventilation of day and night rooms is not to be overlooked. Exercise has been 
mentioned. If increase is needed or greater variety, this must usually be 



184 PSORIASIS 

advised in connection with one's vocation or daily routine of work or pleasure. 
For those with leisure the various active games, riding, driving, etc., will sug- 
gest themselves. Sunlight is beneficial and it is interesting to note that psori- 
asis is not common on the exposed parts. No cast iron rule can be made for 
attention to all physiological needs, and explicit directions, therefore, while 
important, must be within the capacity of the patient to carry out. Nearly 
every one can take a cold towel bath morning or evening, with the exercise 
incident to thorough friction of the whole skin, and find it not only beneficial 
but refreshing. Water has decided therapeutic uses in psoriasis. The cold 
spray or needle bath over the spine for a few moments at the end of an ordinary 
daily bath, or the cold pack occasionally, may be very beneficial by its action 
on the nervous system, while the Turkish bath once a week is of considerable 
local value. Water internally in sufficient quantity to facilitate transference 
and elimination is important in this as in many other diseases. For the well- 
to-do, change of scene, or climate may be advisable. Many cases thrive in a 
warm climate during the winter months, especially if a course of bathing in hot 
natural spring water can be taken. The Virginia Hot Springs and some in 
Arkansas have been of service combined with other treatment. The editor 
has noted marked benefit to follow the use of the natural baths at Mt. Clemens 
and at the Crockett Springs (Virginia) in four instances. Pure water is to be 
preferred to the mineral waters for internal consumption. Tonic effects may 
be produced by general galvanization, faradization, static electricity and high 
frequency currents. 

Having corrected physiological errors by physiological methods so far as 
practicable in a given case, the patient is in the best condition to respond to 
an indicated drug. This should be selected and administered before local treat- 
ment is instituted, and in many cases the latter can be dispensed with alto- 
gether. There can be, however, no valid objections to local mechanical meas- 
ures for loosening and removing accumulated scales. 

Frictions with simple oil or fat may be thoroughly made in the morning, 
and then the surplus fat and loose scales wiped off with a towel or gauze. If 
the eruption is extensive this takes time when well done. The application may 
be made again at night, followed by a warm bath with frictions, with simple 
soap and a nail brush employed to remove the scales. This method of freeing 
the patches of scales can be repeated every day or only often enough to keep 
the patches clear. When the scaling is moderate or in acute cases, especially 
in children, a daily bath made all-aline by the addition of two to six ounces of 
sodmm carbonate, sodium bicarbonate, sodium biborate or sodium hyposul- 
phite, will suffice to remove the scales. If the skin becomes dry a simple 
ointment of equal parts of petroleum and lard may be used. Salicylic acid 
from its well known effect on corneous tissue can be made use of to reduce 
circumscribed scaling. For this purpose a five to ten per cent, ointment can 
be used in place of the simple fat mentioned above, or when the lesions are 
not extensive a more convenient method of applying salicylic acid is in the 
shape of a varnish composed of half a drachm of the latter to an ounce of 




Fig. 56— PSORIASIS 

ANNULAR, CIRCINATE VARIETY 

Patient is a man of twenty-five, well-nourished and otherwise in good health. 
Family history negative. He states he has been troubled with a scaly eruption for 
five years, and that when the lesions become circular in shape they persist as such 
until another outbreak occurs. Mild sensations of burning are felt for a few hours 
after the scales fall or are rubbed off. The lesions are nearly covered with rather 
adherent whitish, dry scales. Cured with kali bichrom., sixth decimal. 




Fig. 57 — PSORIASIS 

GENERALIZED INVETERATE TYPE 

Patient, a man of thirty-five. Duration, fifteen years. 
Patches had been painted with chrysarobin just before being 
photographed, hence the marked pigmentation of the psoriatic 
patches and the apparent lack of white scales. Local treat- 
ment was temporarily successful, but the condition returned 
in the following winter, when he came to our notice in the 
condition above depicted. 






PSORIASIS I 85 

traumaticine or collodion. After the bath following the first application of 
simple fat, it can be painted over the patches with a brush and allowed to 
remain for twenty-four hours, at the end of which a warm bath will loosen the 
coating of varnish so it can be lifted off and the surface well cleansed. The 
painting can be repeated after the bath daily, or as often as needed to keep 
the surface free. The effects of these applications are purely local and relieve 
the diseased skin from the irritation of its own product, and hence further 
the action of internal remedies. If it becomes necessary to produce local 
pathogenetic effects later, which I believe is seldom advisable, other applica- 
tions can be employed. I have rarely made use of them and cannot speak from 
much personal experience. When there is more than average persistency of 
the lesions with thickening of the skin, frictions with tincture of green soap 
may be used every two or three days, followed by a protective application of 
some kind. The soap thoroughly removes the scales, aggravates the irritation 
of a patch, which is followed by improvement as the latter subsides. The effect 
on each patient must determine the frequency and number of repetitions of the 
frictions, the object being by gentler and less frequent aggravations to bring 
about a return of normal nutrition. "With a disappearance of the thickened 
condition of the skin the use of the tincture of soap should be discontinued. 
When the patches are few and small in area, chrysarobin is, perhaps, the most 
effective stimulant. Its drawbacks are the danger of toxic effects and over- 
irritation of the skin from its incautious use, and the disagreeable stains it 
makes on the skin and clothing. The latter objection has led me to discard it 
altogether in ointment form and only employ it in flexible collodion, traumati- 
cine or chloroform, which, when dried, does not stain the linen. It is not 
suited for use on the face or other exposed parts. Dissolved in traumaticine 
in the proportion of ten to forty grains to the ounce, it can be painted with a 
brush over the smaller patches and permitted to remain until it begins to 
separate at some part, when a warm bath will remove it altogether. The var- 
nish can be renewed at once, or after an interval, when improvement again 
ceases. When the stronger solution (thirty to forty grains to the ounce) is 
required, chloroform is a better vehicle. This is well rubbed on to the patches 
with a stiff brush. The subsequent course is the same as when traumaticine is 
used. Flexible collodion has no advantage over other vehicles except on parts 
of the skin subject to greater motion. If there are many lesions a few each 
dav can be treated with greater safety. Beta naphthol or ammoniated mercury, 
in the strength of fifteen to ninety grains to an ounce of vaseline, is useful in 
eases needing mild pathogenetic effects. Thymol is adapted to similar cases 
and may be used in like proportions. Resorcin, ten grains to two drachms 
to an ounce of fresh lard, makes a cleanly application, the strength of which 
can be graduated to the age and the effect desired. Either of the three last- 
named drugs can be used on the face, where the eruption in children is not 
uncommon. The mercurial ointments (except the above-mentioned) have 
been recommended as useful local stimulants in psoriasis, but the objections 
to their employment are greater, without their possessing any qualities superior 



186 PSORIASIS 

to the applications already named. Neither does the use of pyrogallol, tar, 
turpentine, liydroxylamin, engallol or eurobin, give results over less objection- 
able applications great enough to compensate for their disagreeable or danger- 
ous properties. 

Light baths have been used for therapeutic purposes. The most efficient 
is that of the sun, but it is unreliable and impracticable. The arc light is 
the best, although baths from numerous incandescent lamps have some value. 
Radiotherapy, while based on the same theory as the sun-bath, presents better 
clinical possibilities. The most satisfactory results are obtained in those 
cases of inveterate psoriasis in which the lesions are few and circumscribed 
or localized. Hyde reports entire removal of lesions in fifty per cent, of his 
cases treated with the Eontgen rays and the editor has obtained equal results 
in forty per cent, of his cases. Many patients will not persist with the treat- 
ment or do so irregularly and hence statistics are not satisfactory. A soft 
tube is-^used covered by a Friedlander hood, at a distance of six to twelve inches 
from the patient, with exposures varying from four to ten minutes, twice a 
week for three weeks. Then discontinue for ten days to permit involution. 
The whole procedure can be repeated if necessary, but usually results will be 
noticed by the fifth or sixth treatment. It cannot be said at this time that 
this method is superior to, or that it gives more permanent results than other 
local measures, but it is cleanly, simple and the use of the rays for short periods 
minimizes the danger of developing a severe dermatitis. At the present writ- 
ing the Finsen light and radium present no advantages over the X-rays. 

The use of arsenic (usually Fowler's solution), potassium iodide, sodium 
salicylate or salicin in material doses, do not yield results that are spectacular 
or satisfactory; however, individual cases are sometimes benefited by a short 
course of physiological medication. The same may be said of the iodo-nu- 
cleoid, a new pharmacal preparation. 

A number of our colleagues have reported cures with the aid of Thyroidin, 
2x or 3x, empirically prescribed. The editor experimented extensively with 
this substance and has seen good results follow its use in a small number of 
cases. 

Internal pathogenetic treatment is the most important and the most diffi- 
cult to select, owing to the poverty of symptoms obtainable in a majority of 
cases of psoriasis. Still a study of the constitutional type, history of other 
antecedent diseases or attacks, together with the peculiarities of the individual, 
will nearly always furnish a basis for drug selection. See indications for 
Agnus cast., Arnica. Arsen.. Asterias rub., Borax. Cal. fluor., Canth.. CarboJ. 
acid, Colch.. Ilydrocot., Iris ver.. Kal. birhrom.. Lycop.. Siangan, Merc, vivus. 
Mez., Nat. arsen.. Phyto.. Petro., Sul., Thuja. 



DERMATITIS EXFOLIATIVA '"■ 

DERMATITIS EXFOLIATIVA 

(Pityriasis rubra; Pityriasis rubra aigu.) 

Under various terms rare exfoliating affections oi' the skin unassociated 
with the common cutaneous diseases, such as psoriasis, eczema, etc., have 
been described by different observers. Considerable confusion exists as to 
whether they are distinct diseases or clinical variations of one disorder. 
Crocker (Diseases of the Skin, 1903, p. 389) takes the latter view, and treats 
of them under the general head of pityriasis rubra. While holding the same 
opinion, the more frequent occurrence of what is ordinarily described as 
dermatitis exfoliativa leads me to prefer the latter as a general name. At 
the same time a term which indicates a pathological condition is to be pre- 
ferred to one indicating a symptom, however prominent. 

Definition. — An inflammatory disease of the skin, primary or sec- 
ondary, becoming general or often universal in its distribution, and char- 
acterized by a pronounced redness of the surface, with abundant and 
repeated desquamation of various sized papery scales. 

Symptoms. — The eruption may appear without any prodromal symptoms, 
or its onset may be attended with general feelings of illness, gastric disturb- 
ances, loss of appetite, sometimes a chill and other pyretic symptoms. An 
evening temperature of 101°-104° has been observed, but the fever rarely con- 
tinues. The redness, which may vary from a bright to a violet hue, more often 
begins about the flexor junctions of the extremities, such as the groins, axillae, 
etc., but it may appear on any part, or several at the same time. Wherever 
arising it commonly extends, meets new points and often rapidly (in two 
days to three weeks) spreads over the whole integument, and is generally 
accompanied with moderate sensations of formication, itching, tingling or 
tension. After a variable time, usually not later than the third week, the 
skin assumes a drill and deeper color, and scales of various sizes form, being 
usually largest on the back, where they may be an inch or two in their largest 
diameter, and smallest on the face, designated as branny desquamation. The 
scales appear to be formed by a rapid drying and separation of epidermic 
epithelia, which remain for a time attached at the centre or margin, presenting 
a fluffy look, or when the flakes are large resembling plates of armor. Separat- 
ing at the natural lines of the skin gives them often a ribbed arrangement. 
When detached they resemble torn pieces of brownish tissue paper, and in 
marked cases the exfoliating scales may fill a pint or larger measure in 
twenty-four hours. If the scales are removed, the skin may be found under- 
neath smooth, dry or moist, but the scales very soon re-form. In fact, the con- 
tinuous exfoliation of the epidermis is the most characteristic feature of the 
disease. After a time the palms of the hands and soles of the feet may become 
involved, and here the exfoliation may occur in large pieces or in casts like a 
glove. In extreme cases the appendages of the skin suffer or are more or less 
completely destroyed; baldness results, and the nails may be shed after be- 



188 DERMATITIS EXFOLIATIVA 

coming deformed (see hypertrophy of the nails). The earliest stages of 
dermatitis exfoliativa are not often seen by physicians, and sometimes there 
is a history of a first eruption of papules, vesicles, bulla? or squamous lesions. 
Again, it may follow eczema, psoriasis, pemphigus, etc., without any great 
difference in its ultimate manifestations. Sometimes in its course there may 
be irritating fluid exudations on the surface, or in the shape of small or large 
vesicles (Devergie). These are most likely to be situated on parts of the 
skin in contact, as beneath the breasts of women, the axillae, inner part of 
the thighs, etc.; they may be temporary, persistent or recurring. One patient 
under my observation has had for several years an annual eruption of vesicles 
during the warm season attended with malaise, headache, fever, etc., and fol- 
lowed by an aggravation of the general exfoliation. 

The disease begins, as a rule, in adult life, and may go on with varying 
remissions (sometimes apparently quite disappears) for years; or in most 
favorable- cases for only weeks or months, averaging less than a year. As the 
disease pursues its course various special symptoms or complications are apt 
to appear. Itching may be most pronounced when the disease is least active, 
and heat or burning are seldom constant. There is always sensitiveness to 
cold, at times the roughened and contracted skin is a source of discomfort; 
while in the latter stages thickening and constriction may interfere with 
motion, cause ectropion, etc. (Edema, boils and infiltration of the more super- 
ficial lymphatic glands are not uncommon. Constipation or diarrhoea may 
become troublesome; inflammation of the mucous membranes of the mouth, 
bronchi, stomach, eyes, frequently occurs. The urine often contains an excess 
of urates, and renal and cardiac complications may supervene to further 
impair nutrition and the already existing general debility and cachexia. In 
fatal cases, death may result from exhaustion, or frequently some acute disease 
like pneumonia or pleurisy may end the scene. 

In the rarer form of exfoliation of the epidermis termed pityriasis rubra 
(Hebra), the disease is usually more insidious in development, persistent in 
course, profound in its ultimate effects on the general health and nearly always 
fatal in result. It may begin with a hardly noticeable hyperaemic redness of 
some part of the skin, which gradually widens in extent, perhaps for a long 
time without any inconvenience to the patient, though the same sensations 
in the skin of formication, chilliness, burning, etc., as in dermatitis exfoli- 
ativa, may be experienced in slight degree. As the redness extends it increases 
in intensity, deepening into a venous hue, especially on the legs; the surface 
becomes dry and comparatively small scales form, fall off, and are constantly 
removed. The scales are never as extremely large as in the first form, but may 
aggregate in quantity in marked cases quite as much as in the latter. Months 
or years may pass while the disease completely invades the whole skin and 
attains its full development. Finally the hair and nails are affected, the 
natural secretions of the skin cease, atrophy and contraction begin. The 
skin loses its red color, becomes thin, parchment-like and constricted; the 
latter condition interferes with the movements of the body, changes the ex- 



DERMATITIS EXFOLIATIVA 189 

pression of the features, produces ectropion, etc. The general health is little 
disturbed at first and the appetite unimpaired, but eventually both give way to 
increasing weakness often aggravated by renal disease, gangrene of the skin 
over some joints, and superficial glandular infiltration and degeneration. 
After a variable duration, frequently running into years, death may occur 
from marasmus, asthenia, or be hastened by pneumonia, bronchitis, etc., as 
in the fatal cases of the more common type. 

Typical cases of pityriasis rubra are characterized by features distinct 
from typical cases of dermatitis exfoliativa, such as its obscure origin, insidi- 
ous development, absence of moisture, finer scales, atrophy of the skin, and un- 
interrupted course to a fatal issue, but in many ways the likeness is close and 
in instances of death from each much the same. According to Jadassohn, who 
reviewed very fully the reports of other observers, thickening of the skin 
sometimes occurs in pityriasis rubra, desquamation may appear in large instead 
of fine scales, slight moisture may sometimes be observed and the prognosis is 
not absolutely hopeless. Kaposi mentions two cases that probably recovered. 
Altogether there is much to support the identity of these two forms of inflam- 
matory exfoliation of the skin. 

Etiology and Pathology. — The disease may occur at any age, but most 
cases begin between the fortieth and sixtieth years of life. Males are nearly 
twice as liable to the disease as females. Antecedent psoriasis, eczema and 
lichen have been noted, and may have had an etiological relation with or with- 
out an underlying tendency to rheumatism or gout. In eleven out of eighteen 
cases reported by Crocker (Paris Dermatological Congress) there was an asso- 
ciation with rheumatism or gout, which supports the view that it is a diathetic 
affection. Some cases seem to be of septic and parasitic origin. Frequent 
association with tuberculosis was noted by Jadassohn in Hebra's pityriasis 
rubra, chiefly involving the lymphatic glands and the lungs. Death has been 
sometimes due to phthisis, but whether it was secondary in order of occurrence 
is not clear. Among other causes alcoholic intoxication (the editor has treated 
two cases apparently due to this cause), chills, applications of chrysarobin, 
arnica, iodoform and mercury, have been mentioned. Probably these acted as 
exciting factors only, some indefinite diathesis previously existing. The patho- 
logical origin is obscure. While histological investigation has shown the 
process to be a dermatitis, it has not determined whether this is primary or sec- 
ondary to some disturbance in the central or peripheral nervous system. Signs 
of both have been found before or after death, but are largely overbalanced by 
negative evidence. Whatever the primary sources of pathological change, the 
inflammation of the skin is at first superficial, later involving the entire skin, 
followed by connective tisue hyperplasia, which, in advanced cases, undergoes 
cicatricial contraction with abundant pigmentation, and the appendages of 
the skin disappear. In the epidermis the granular layer is thinned or obliter- 
ated, the mucous layer more or less thickened, and its cells failing to pass 
through the intermediate process of development for cornification, are pushed 
outward to form the imperfect and thickened horny layer, from which are 
shed the scales characteristic of the disease. 



190 DERMATITIS EXFOLIATIVA 

Myelitis has been noted by Jamieson, and Quinquaud and Laneereaux have 
described both peripheral and central inflammatory nerve changes. Kanshalter 
found a microbe resembling staphylococcus albus, but its pathogenic character 
remains to be determined. It may be that the primary cause will be discovered 
in some bacillus or toxin acting on the nervous system. 

Diagnosis. — The two types of dermatitis exfoliativa may be distinguished 
from each other by the differences of development and course. Pityriasis 
rubra, so called, is insidious in development, continuous in course and is 
attended with a branny desquamation; in comparison with the acute develop- 
ment, variable course and large scales of the more common form. Little diffi- 
culty will be found in diagnosing a well-developed case of either form from 
psoriasis, squamous eczema, lichen rubra, scarlatiniform erythema or pemphi- 
gus foliaceus. 

Psoriasis is rarely or never universal in distribution, and has little or no 
effect on the general health; the earlier lesions are round or circular and are 
soon covered with pearly scales, which adhere to each other, instead of the 
eruption being diffused and the scales thin and easily detached, as in dermatitis 
exfoliativa. 

In generalized eczema there are sound portions of the skin here and there ; 
nearly always there will be a history of multiple lesions, moist exudation and 
intense itching; the scales are not thin and papery or extremely abundant, 
as in exfoliating dermatitis, but yellowish, comparatively scant and more 
adherent. 

Lichen ruber begins with characteristic papules, and when it becomes scaly 
some papules can usually be found ; it is rarely universal, and when generalized 
there is often a marked difference in appearance of different parts of the skin. 
The possibility of exfoliating inflammation of the skin following the above 
diseases as well as from the effects of some drugs may be of importance in 
diagnosis. 

Erythema scarlatiniforme may be distinguished from dermatitis exfoli- 
ativa by its short duration, and though the scaling may resemble either form 
of the latter it is not continuous. 

Pemphigus foliaceus is a rare disease, but may present a close resemblance 
to the more common form of exfoliating dermatitis, but it always begins with 
the formation of flaccid bullae, though the latter may rupture so quickly as to 
be overlooked. A careful investigation of the history of the attack and the 
presence of a nauseating odor will seldom fail to identify that disease. It is 
to be remembered that bullous lesions may occur in the course of dermatitis 
exfoliativa, but are never general or continuous. 

Prognosis. — This is not so grave as was once thought. It is unfavorable 
at the extremes of life, when following on some exhausting disease, or occurring 
in the debilitated or weakly. Even pityriasis rubra is not entirely hopeless. 

Treatment. — The indications are to correct and improve the nutrition by 
regiilation of the diet, to give protection to the diseased skin by mechanical 
methods, rest in bed, etc., and to overcome the systemic condition bv the use of 



DERMATITIS EXFOLIATIVA EITDE.MICA IM 

a constitutional remedy. The food must be adapted to the capacity of the 
digestive organs, which are liable to be impaired by the disease. Sometimes a 
milk diet is advisable; more often a selection of easily digested vegetable and 
animal food is best, preference being given in most cases to vegetables, espe- 
cially if the patient is not anaemic. Cod liver oil or sweet oil may be used with 
advantage for the anaemic. 

Locally the abraded skin should be protected by frequent applications of 
simple fat or oil and covered with a bandage of closely fitting linen or cotton 
underclothing. A warm (sometimes hot) bath to which bran, gelatin or starch 
has been added, may be taken daily, always remembering to apply the oily 
dressing afterwards. Plain petrolatum or a cooling salve, like cold cream, may 
be used instead of an oil. Crocker recommends wrapping the patient in 
bandages soaked in linimentum calaminae. A two per cent, calendula oint- 
ment has proven efficacious. If the attack is at all severe, the patient is best 
kept in bed for a time and linseed oil abundantly applied to the skin, a rubber 
cover being placed under the sheet to protect the bedding. "When patients 
begin to go about they should wear flannels over the linen or cotton under- 
clothes, and carefully avoid changes of temperature or exposure to drafts. 
For internal treatment see indications for Arsenicum alb., Bell., Colcli. and 
Mez. 



DERMATITIS EXFOLIATIVA EPIDEMICA 

(Epidemic eczema; Epidemic skin disease.) 

Within a few years there have been reported as occurring in several Eng- 
lish charitable institutions an epidemic skin disease sometimes resembling 
eczema, but always resulting in desquamation of the epidermis, similar to 
that of dermatitis exfoliativa, with more or less antecedent or concomitant 
symptoms of anorexia. 

Symptoms. — In most cases the eruption, beginning in the summer, was the 
first sign of the disease, and appeared in the form of irregularly grouped, 
acuminate papules located at the hair follicles. With or without the grouped 
lesions merging into patches, the eruption slowly or rapidly spread until the 
wbole surface became a deep red color and covered with abundant scales. 
Usually the eruption was s}omnetrical, but in a few cases seemed at first 
localized and later became general. In a less number of cases the eruption 
developed from round, defined erythematous patches or flat papules. Some- 
times the latter enlarged at the border and became vesicular in the centre, and 
in many cases of the most common type the papules became vesicular on the 
second or third day. ruptured and gave exit to a moist discharge character- 
istic of eczema. "Whatever the type of initial lesion or subsequent evolution 
the final exfoliation of the cuticle followed, and in the absence of moist 
exudation was objectively nearly identical with exfoliating dermatitis before 
described. There was an absence of fever in most cases: vomiting, diarrhoea 



192 DERMATITIS EXFOLIATIVA NEONATORUM 

and sore throat occasionally occurred. Conjunctivitis occurred in most cases. 
Many cases had swelling and tenderness of the glands of the neck; the skin 
was deeply pigmented on recovery, and in severe cases the nails and hair were 
shed. The duration in well marked cases was from six to eight weeks ; many 
had relapses and a few had second attacks. The disease showed a decided 
tendency to attack the aged, and was more fatal with the male sex, one report 
giving the mortality of females as about four per cent, and that of males over 
twenty per cent. Death generally resulted from exhaustion, or from complica- 
tions such as pneumonia, renal disease, gangrene of the feet, etc. 

Etiology and Pathology. — Nothing positively is known as to the causes. 
The facts that nearly all cases occurred in institutions whose inmates were 
somewhat disabled by age or disease, of whom about one in five contracted the 
disorder, and that the eruption spread by peripheral extension, point the origin 
in some form of local contagion. Micro-organisms were found in the lesions, 
and Savill and Eussell found a rod-like segmented diplococcus in the blood, 
tissues~"and exudations. The food and milk supply were suspected as the 
possible vehicle of contamination. A rabbit inoculated with a culture devel- 
oped after five days a red and scaly skin without constitutional symptoms, 
but died as the eruption subsided from no other apparent cause. Pathologi- 
cally the disease is a dermatitis attended with more or less serous effusion and 
extravasation of leucocytes in the corium and engorgement of the vessels. 

Diagnosis. — The characteristic features of the disease ought to make its 
recognition easy after the lapse of a few days. These are its epidemic nature, 
absence of fever, preference for the aged, comparatively short course, apparent 
contagiousness, development and spread of the eruption, its resulting desqua- 
mation and large mortality. In some one or more ways it might resemble 
erysipelas, eczema, dermatitis exfoliativa, ringworm or rotheln, but the absence 
of other diagnostic evidences of those diseases would be plainly noticeable. 

Treatment. — Early local antiparasitic measures seem to have yielded the 
best results. Crocker recommends painting the lesions, if they are limited, 
with tincture of iodine or collodion. In the stage of desquamation soothing 
applications, as indicated for dermatitis exfoliativa, ought to be serviceable. 
Sustaining the strength by a suitable dietary is important. Arsenicum is 
likely to be the best indicated internal remedy. 



DERMATITIS EXFOLIATIVA NEONATORUM 

(Ritter's disease.) 

This cutaneous disease of the new. born has been chiefly studied and 
described by Bitter of Prague, who for several years observed nearly three 
hundred cases in the Foundling Asylum there. Several other Continental der- 
matologists have reported one or several cases, and in this country several 
cases have been recorded. 

Symptoms. — The disease is described as beginning usually between the first 






DERMATITIS EXFOLIATIVA NEONATORUM 198 

and third week of life, as a diffused redness, often about the mouth and other 
parts of the face, sometimes elsewhere on the body, and occasionally is uni- 
versal at once. If starting in patches, it spreads in a few days all over the 
surface, reaching the extremities last, as a rule. Desquamation follows rapidly 
at the first point of origin and occurs in either branny or larger scales of all 
sizes. These may be easily removed as they loosen at the edges, and under- 
neath reveal a new epidermis. Sometimes a dry and scaly condition of the 
skin follows the normal changes in the epidermis after birth and precedes 
the redness. This probably led Kaposi to regard the disorder as an aggravation 
of the physiological exfoliation of the new born. On the other hand, the 
exfoliation may be preceded by a fluid exudation in the form of minute 
vesicles or in large flaccid bullse as in pemphigus foliaceus. In severe cases of 
the latter type, when the roof walls of the blebs have been rubbed off, the skin 
may look as if it had been scalded. After desquamation is over a regenera- 
tion of the epidermis occurs quite rapidly, as a rule. The mucous surfaces of 
the mouth, nose and eyes may be affected. There is little or no systemic fever 
or other general symptoms unless complications arise. If relapses occur they 
are commonly mild. Marasmus may supervene m severe cases ; and boils, other 
pustular inflammations and gangrene may follow the disease. The duration 
is usually from one to two weeks, but may be prolonged from various causes 
or cut short by death in a large per cent, of the severer attacks. 

The causes are not known, though the parasitic theory of its origin seems 
reasonable ; it has not, however, been proven. Neither is the pathology at all 
clear. Some believe with Kaposi, that it is a perversion or excessive physiologi- 
cal exfoliation of the epidermis of the new born with secondary hyperemia 
rather than a pure dermatitis. The absence of pyrexia would indicate that it 
might be an acute disturbance of the nutrition of the epidermis due to a gen- 
eral cause, or, as Elliot has suggested, of those layers of the skin not contain- 
ing blood-vessels. 

Diagnosis will seldom be difficult if the age, development and rapid exten- 
sion of the eruption and absence of fever are borne in mind. The cases at- 
tended with the formation of blebs might be confounded with acute pemphigus 
of the new born or with pemphigus foliaceus. The former begins with an erup- 
tion of discrete bullae surrounded by a pinkish areola, usually appearing before 
the end of the first week, rarely after the end of the second week of infancy, 
and continue to appear in crops for a week or two. Pemphigus foliaceus nearly 
always occurs in adult life and runs a chronic course. 

The prognosis is grave as given by a mortality in the reported cases of 
about fifty per cent. 

Treatment should consist in frequent nourishment, protection of the sur- 
face with fat or oil and the administration of an indicated drug. For local 
application a nutrient fat or oil like lanolin (properly diluted) or sweet oil 
can be chosen. Lanolin has the further property of a moderate antiparasitic, 
which may give it additional value in this affection. For internal remedies 
see especially Arsenicum and its salts. 



194 DERMATITIS GANGRENOSA 



DERMATITIS GANGRENOSA 

It is known that many different agents can cause a dermatitis which eventu- 
ally becomes gangrenous. Among these may be mentioned excessive cold or 
heat; chemical agents applied externally; drugs ingested; infectious diseases 
like lepra, tuberculosis., etc. ; diseases of the central nervous system ; embolism, 
thrombosis and other diseased conditions of the blood-vessels even when caused 
by ligatures, tumors or inflammatory processes. 

Multiple gangrene has been reported by Crocker as following scarlatina, 
by Hahl as complicating typhoid fever, by Osier as occurring with malaria, 
etc. The lesions seem to be auto-inoculable and bacilli and cocci have been 
found in them. It would appear that the local infection was made possible 
by the diminished power of resistance present in the diseased tissues. 

Hysterical gangrene. — "Spontaneous" gangrene of the skin has been 
described by Kaposi as a disease noticed by him in hysterical and anaemic young 
women; but being regarded as possibly an imposture, it has not been generally 
accepted by dermatologists. Kaposi describes the lesion as a raised and some- 
what red spot, varying in size from a shilling to a crown piece, accompanied 
with a burning sensation. In a few hours the skin becomes bluish-black or 
greenish-brown in color, and a leathery eschar is formed like that produced by 
sulphuric acid. A hypertrophic cicatrix follows. The process is repeated in 
other parts at intervals of days or weeks, and this may continue for months 
or years before finally stopping. A like case of my own responded to Hyos- 
cyamus. Among other possible remedies are Arsenicum and Kreosoium. 

Diabetic gangrene. — Unilateral or bilateral gangrene of the foot, or other 
portion of the skin of the lower extremities, rarely of the penis, fingers, etc., is 
one of the less frequent affections of the skin associated with diabetes. It is 
primary in local origin, or may be secondary to slight injuries, furuncle, phleg- 
mon or anthrax. The lesion passes through the stages of inflammation, the 
formation of bullae and sloughing. A form described by Kaposi of bullo- 
serpiginous gangrene begins in blebs, which ulcerate and heal at one side while ' 
progressing on the other. The chief cause of diabetic gangrene may be the low 
resisting power of the tissues Avhich diabetes occasions, permitting an easy in- 
vasion of micro-organisms, or in primary cases it may arise from neurotic 
sources. 

The treatment is that applicable to diabetes, together with local antisepsis, 
and rarely surgical interference when septicaemia is impending. Local or gen- 
eral symptoms may indicate Arnica, Arsenicum or Kreosoium. 

Symmetrical gangrene will be discussed under neuropathic affections 
(Class IV.). 




Fig. 58— HYSTERICAL GANGRENE 



MULTIPLE GANGRENE OF ADULTS 

Patient is a neurotic unmarried woman, about twenty-two years of age. She 
is excitable and loquacious, gives a history of a superficial scald of the left leg two 
years ago; since that occurrence various paresthetic sensations in the skin below 
the left knee and muscular twitching in the extremities have been felt at times. 
Duration of larger lesion three months; two smaller, four to six weeks. They are 
dry, without signs of inflammation or discharge, even in the line of demarcation, 
but appear to be tender and painful. The unbroken skin on the inner aspect of the 
leg is dry and moderately and unevenly hyperaemic. Cured with hyoscyamus, 
second decimal. 



DERMATITIS GANGRENOSA INFANTUM l'-'-"' 



DERMATITIS GANGRENOSA INFANTUM 

[Pemphigw gangrenosus; Varicella gangrenosum; Rupia eschar otica; Multi- 
ple cachectic gangrene, etc. ) 

Definition. — A gangrenous inflammation of the skin of unknown 
origin, but often following varicella and other pustular eruptions of child- 
hood. 

Symptoms. — When first described by Butchinson in 1882'the disease was 

looked upon as secondary to varicella, but since then it lias been observed after 
other diseases of the skin in children, and sometimes without any history of 
antecedent cutaneous disease. If the onset is during the course of chicken-pox 
or other eruptive disease, some of the lesions instead of resolving take on a 
new process. A red or purplish areola appears; ii' crusts are present, pus may 
form under them, vesicles soon become purulent, or pustules may form in- 
dependent of vesicles. The lesions with or without rupture and crusting 
may increase in size to a fourth of an inch or larger in diameter and become 
covered with an adherent, sometimes blackish crust. When they have attained 
a variable size, the process of separation begins and extension generally ceases. 
The ulcer, which is left after the necrotic mass is thrown off, is round or oval 
with a rather hard edge, precipitate sides, varying in depth with the size, but 
often extending into the corium or even into the subcutaneous layer, and con- 
tains purulent masses of dead matter. If lesions are near together, they may 
coalesce and result in large, irregular ulcers. When the eruption begins apart 
from the site or independent of any previous lesions a small papulo-pustule 
arises on an erythematous base, enlarges to the size of a pea or larger and forms 
a central crust, sometimes with a pustular border, much like the vaccine pus- 
tule. .The subsequent course may be the same as in those following on the 
lesions of a previous disease. Unconnected with antecedent lesions the disorder 
is commonly located on the lower half of the body, especially on the buttocks 
and thighs. Here the lesions may be quite numerous and the skin thickly 
studded with all sizes. On the other hand, they may be few in number and 
isolated; or the lesions may be little more than pustules with slight tendency to 
become gangrenous or produce more than very superficial ulceration. Crocker 
mentions cases which pursued a malignant course from the first, with hemor- 
rhage into the vesicles, ended fatally, and showed post-mortem evidences of 
pyamiic infection. He also states that the eruption may be primarily bullous 
in form. In a case under my observation, hemorrhage occurred into a few of 
the lesions, which were located on the buttocks, but recovery followed without 
extreme symptoms. In severe cases constitutional disturbances may occur 
early, and if purulent absorption follows, pyaemic symptoms may appear. 

Etiology \nd Pathology. — This is an affection of early childhood: the 
youngest case recorded was three months, and the oldest under three years. The 
majority were in the first year of life. Kaposi, however, stales that be has 
observed the same disease in adults suffering from such cutaneous inflamma- 



196 VARICOSE ULCER 

tions as psoriasis, lichen ruber and pityriasis rubra. My own cases were all 
under two years of age, and all except one had the attacks come on after some 
pustular eruption, the nature of which could not always be determined; the 
largest per cent, were girls. All were clinical patients, and neglect appeared to 
be at least a contributing factor. Aside from the causal influence of varicella, 
vaccinia, etc., tuberculosis, rickets and congenital syphilis have been named as 
causes. It seems probable that some predisposing constitutional state or dia- 
thesis is the real cause, and that with its temporary accentuation the eruption 
may be excited by the local lesions of certain skin affections, foul secretions, 
micro-organisms, etc. No special organism has been isolated from the lesions 
of the disease, but various forms of bacteria have been found, including the 
staphylococcus cereus albus, the bacillus pyocyaneus and the streptococcus 
pyogenes. 

Diagnosis. — The disease may be easily recognized by its usual occurrence 
in infancy, after other eruptive diseases, or independently, and in the latter 
eventfprincipally on the buttocks, inner thighs or lower extremities ; in charac- 
teristic lesions, which in their evolution form pustules, crusts and gangrenous 
ulcers. Usually the several stages of the eruption may be seen in one case 
at the same time. 

Prognosis. — The disease probably is not in itself of a fatal character, but 
constitutional weakness, cachexia, or some complication may render the prog- 
nosis grave. My own cases all recovered, but they were not extremely severe, 
though one had about forty lesions upon the buttocks and posterior part of the 
thighs, some of them hemorrhagic. 

Treatment. — Absolute cleanliness, mechanical protection and in a few 
cases mild antisepsis meet the local needs. Warm borax water for the first pur- 
pose and a weak boric acid or aristol ointment (five to fifteen grains to an ounce 
of fresh lard) for the latter, is the only local treatment needed for mild cases. 
In cases of undoubted bacterial infection antiseptic local treatment should be 
used, such as boric acid, aristol or ichthyol ointments, five to ten per cent., or a 
1 : 3000 solution of corrosive sublimate. In infants when the eruption is so 
situated that the urine and feces come in contact with it, cleansing and dressing 
may need to be frequent. 

The little patients should be abundantly nourished, perhaps by attention to 
the mother's diet, if the child is nursing. Among remedies see indications for 
Arnica, Arsen., Crotalvs, Kali bichrom., Kreso.. Nit. acid, Secale and Sul. 
acid. 

VARICOSE ULCER 

A varicose ulcer is a loss of substance from a disintegrating and destruc- 
tive process occurring with a varicose state of the veins. 

A phlebitis of the affected veins develops, minute phlebitic points form, 
causing abscesses which become ulcers by molecular death of the dermal struc- 
ture and of the surrounding tissue. Thev usuallv enlarge bv coalescence of 






VARICOSE ULCER •••' 

a number of such ulcers, hence are generally irregular in outline with under- 
mined edges. In appearance these ulcers resemble the simple chronic variety 
elsewhere, with the addition of a deep blue color of the granulations. An 
eczema rubrum often exists. 

The appearance of a varicose ulcer is more accidental than causal as re- 
gards the varicose veins, because injury to a limb, however slight, is usually 
the exciting cause, while the weakened condition of the surrounding tissues, 
making it difficult to heal, acts as a predisposing factor. Bleeding occurs 
when the veins are opened and may become dangerous if not fatal. 

Treatment is directed to the support, pressure and protection of the vari- 
cose condition, to the destruction of any bacteria and to the stimulation of the 
growth of new tissue. Best in bed, use of bandages to relieve venous conges- 
tion, and the raising of the limb are serviceable in severe cases. It is advisable 
to clean the ulcerating surface, every two or three days, with water as hot as 
can be borne or with a five per cent, carbolic acid solution, or a fifty per cent, 
solution of the peroxide of hydrogen or electrozone. When dry, dust finely 
powdered boric acid on the ulcer, cover with rubber tissue which overlaps the 
ulcer edges by at least an inch, and hold in place with adhesive plaster. Over 
this, gauze is placed and a snug supporting bandage. Dolomol-calendula (ten 
per cent.) or dolomol-ichthyol (ten per cent.) may be substituted for the boric 
acid powder. Balsam Peru or bovinine have given good results when applied 
in connection with narrow adhesive straps which are so arranged as to draw 
the edges of the ulcer together. The editor can add his testimony to that of 
many others that the resonator currents {high frequency) will aid materially 
to heal some chronic ulcers. The increased flow of arterial blood and the 
liberation of ozone are the working factors in this instance. A glass electrode 
is used to concentrate the current and is held near to the ulcer without being 
in contact for one to three minutes bi-weekly. Colleville recommends the 
Rontgen rays in the treatment of varicose ulcerations, but further experience 
is needed before testifying to the efficacy of this method. 

Internal medication might demand — Calcarea fivorica, ulcers on the legs, ex- 
tensive varicosities, worse in a dependent position. Nitric acid, sensitive, offen- 
sive odor, pricking pains, readily bleeding, difficult to heal, worse from touch 
and cold water. Kali bichromate, dry, deep, oval ulcers, edges overhanging, 
bright red areola. Sulphur, raised, swollen, jagged edges, much pus, cedematous 
swelling and reddish-brown discoloration of the skin. Hamamelis and the 
mercurials may also be studied. 



198 PITYRIASIS ROSEA 

PITYRIASIS ROSEA 

(Pityriasis maculata ei circinata; Herpes tonsurans maculosus.) 

Definition. — An acute affection of the skin characterized by small 
primary papules which soon develop into slightly elevated round or oval 
maculae, varying in size, of a bright or pale rose color and covered with thin, 
adherent branny or finer scales. 

Pityriasis rosea is one of the less common skin diseases, constituting .135 
of all cases as compiled from the reports to the American Derma tological As- 
sociation. It was first clearly described in this country by Duhring in 1880, 
without knowledge of the previous recognition of the disease by Gibert and 
Bazin in France in 1868. 

Symptoms. — There may be moderate premonitory sensations of malaise, 
fever, loss of appetite, etc., or they may attend the full development of the erup- 
tion. More often general symptoms are altogether absent or unnoticed. The 
appearance of the eruption in two forms is indicated by the name sometimes 
used, pityriasis maculata et circinata. When seen only in the macular type or 
stage, the patches may vary in size up to one or two inches in diameter, be 
roundish in outline or sometimes irregular, ill-defined, of a pale red color, 
which partly disappears on pressure. The lesions reach their size by peripheral 
growth, and until the eruption is fully developed the smaller patches may con- 
tinue to enlarge. Barely the eruption may become confluent in larger patches, 
or more or less diffused. More often the patches remain distinct but quite 
widely distributed, and occasionally only one or two macules appear. In a 
few days the centre of the macule begins to fade and assume a wrinkled old- 
parchment yellow or fawn-color, while the border remains reddish and elevated. 
When the process of evolution is nearly or quite complete in the centre of the 
large patches, they become converted into ring-like lesions and constitute the 
circinate form first described by Bazin. The separate rings may continue to 
enlarge, and melting at the junction with other circular patches form gyrate 
patches of more or less extent. With or without the latter enlargement, the 
patches gradually fade away in the order of their occurrence, leaving pale fawn- 
colored stains which gradually disappear. 

The common location of the eruption is on the abdomen or chest, but it 
may extend to the thighs, legs or arms, and occasionally becomes widely dis- 
tributed, very rarely, however, encroaching on the surface of the face, scalp, 
hands or feet. The distribution of the eruption is symmetrical; it is always 
dry and is rarely attended with any marked subjective sensation. Itching may 
be noticed at night, or when the patient becomes warm, but is seldom severe. 
After a duration of from two weeks to two months, the eruption, as a rule, 
spontaneously disappears: exceptionally it may persist for several months. 

Etiology and Pathology. — The causes are not known. The disease may 
occur at any age, though most common in childhood and youth. Bazin at- 
tributed it to the arthritic diathesis, and its svmmetrieal arrangement on the 



PITYRIASIS ROSEA 189 

skin would indicate an internal systemic origin. If such is the case, other lac- 
tors found mentioned, such as excessive heat, free perspiration, irritation from 
clothing, etc., or various gastric disturbances observed by Duhring, Jacquet 
and others, may act as exciters of an outbreak of the eruption. That this dis- 
ease may be exanthematous in nature and mildly infectious, would seem possible. 
Unna and others found that the papillary layer of the corium and the rete 
were chiefly involved in the pathological changes; dilatation of vessels, cell- 
infiltration and cedema occurring in the papillary body, while intracellular and 
intercellular oedema and proliferation of the prickle-cells occur in the rete. 
Minute vesicles, not visible microscopically, form beneath the horny layer as 
the disease reaches its acme, and the absence of phagocytes in these vesicles 
leads Sabouraud to infer that pityriasis rosea is not parasitic, but rather a ves- 
icular erythema of toxic origin. Vidal alone has reported the presence of a 
parasite. 

Diagnosis. — The rose tint, shape, scaliness, old-parchment yellow centre, 
and distribution of the lesions on the trunk, or other covered parts of the skin, 
together with the absence of contagion, marked subjective sensations, and its 
short course, make the recognition of pityriasis rosea comparatively easy. It 
may, however, resemble ringworm of the body, psoriasis, syphilis, seborrhceic 
dermatitis, squamous eczema and tinea versicolor. 

Ringworm or tinea circinata and the circinate form of pityriasis rosea may 
look much alike, but the former is a contagious disease, and often occurs on 
the scalp, in both respects different from the latter. The rapid development 
and commonly wide extent of pityriasis are rarely or never seen in ringworm. 
The presence of the characteristic fungus of ringworm as detected with the 
microscope is positive evidence of its existence. 

Psoriasis does not show a preference for the same location as pityriasis 
rosea; its round or circinate patches are more elevated, of a deeper red, and 
often show the congested or bleeding papilla? on removal of its larger, whiter and 
thicker scales. 

Syphilis is nearly always acquired in adult life, and its early macula? and 
circinate lesions are dark red, apt to appear on the upper parts of the face, on 
the palms of the hands, as well as elsewhere on the skin, whereas pityriasis 
more often occurs in childhood, and is rarely or never seen upon the face or 
palms. Moreover, other evidences of syphilis can usually be found if that disease 
is present. 

Seborrhceic dermatitis of a mild degree may resemble pityriasis rosea when 
it begins to fade and takes on a yellowish tinge, but the scales of seborrhcea 
are fatty, easily removed, and the surface of the patches may become moist, 
or easily bleed if irritated by friction. The scales of pityriasis rosea are dry, 
and friction only effects to roughen the surface of the patch. The latter disease 
is of short duration ; seborrhceic dermatitis may last for months or years. 

Squamous eczema may at some stage exhibit features like pityriasis. It 
seldom preserves a roundish shape or develops into circinate lesions, and does 
not seek the situations common to pityriasis rosea. There is generally a history 



200 



LICHEN 



of moisture with eczema, itching, and when a scaly patch is deprived of its 
scales, a moist exudation is apt to appear, which does not occur in pityriasis 
rosea. 

Tinea versicolor is not likely to be confounded with pityriasis rosea. It 
is never acute in its course, and its patches are yellowish brown rather than 
rose red in color. A microscopic examination of the scales will always show 
the presence of the microsporon furfur in tinea versicolor, and remove all doubt 
of its nature. 

The prognosis is always good. In most cases the disease ends spontaneously 
inside of two months; rarely it may tend to continue longer. 

Treatment. — This may be summed up in local cleanliness, correction of 
any physiological errors of living, and the indicated remedy. Cleanliness of 
the patches may be maintained by the daily use of a mild borax bath, a ten to 
twenty per cent, solution of sodium hyposulphite, or equal parts of alcohol and 
water. --Extensive and pruritic lesions have been relieved by a few brief ex- 
posures to the Rontgen rays. In a few stubborn cases, a two per cent, am- 
moniated mercury ointment or a five per cent, sulphur ointment will facilitate 
recovery. Gastric or other causal disturbances should be met by attention to 
the diet, etc. The choice of a remedy will usually come from symptoms apart 
from the skin (gastric-intestinal, etc.). See among other drugs, Borax, Mez. 
and Nat. arsen. 



LICHEN 

The term lichen has been rather loosely employed in the past in the nomen- 
clature of papular eruptions of the skin. It is now used almost exclusively to 
designate inflammatory papules which undergo no intermediate metamorphosis 
during their evolution, and include the clinical forms of lichen ruber, the more 
distinct lichen planus, and the tubercular form, lichen scrofulosum. The word 
still appears in medical literature in the discussion of certain phases of some 
other diseases, the chief of which are as follows : 

Lichen circinatus (see seborrhceic dermatitis). 

Lichen eczematodes and lichen simplex (see eczema papulosa). 

Lichen pilaris (see keratosis pilaris). 

Lichen strophulosus and lichen tropicus (see miliaria rubra). 

Lichen urticatus (see urticaria papulosa). 

Other uses of the term require no explanation or occur in relation to the 
three types of disease first named. 



LICHEN RUBER 201 



LICHEN RUBER 

(Pityriasis rubra pilaris; Lichen ruber acuminatus; Lichen psoriasis; Lichen 

neuroticus.) 

Much uncertainty still exists as to the proper limitations of this rare dis- 
ease. Many able observers believe that pityriasis rubra pilaris is a distinct dis- 
ease from lichen ruber. Others, that it is the same as lichen ruber acuminatus 
of Kaposi, while some regard it as a form or stage of lichen ruber. The author 
has had an opportunity to watch the course of a well-marked case of so-called 
pityriasis rubra pilaris, and feels that the unity of that clinical type with lichen 
ruber is more than probable. Furthermore, in the existence of a doubt, it seems 
best not to add to the already extended list of individual cutaneous diseases. 

Definition. — Lichen ruber is a chronic cutaneous disease consisting of 
an eruption of small, reddish, conical papules, chiefly situated at the hair 
follicles. These by multiplication and aggregation form, as a rule, large 
infiltrated, scaly patches, producing an apparent deepening of the natural 
lines of the skin. The disease runs a slow relapsing course, which at dif- 
ferent stages or on different parts presents a widely unlike appearance of 
the surface. 

Symptoms. — The primary stage is always papular, lichen ruber papulosus. 
The papules are at first isolated and usually limited to the hair follicles, but 
not invariably so, as at an early stage they have been seen upon the palms of 
the hands where hair follicles do not exist. The papules are pin-head to millet- 
seed in size, pale or yellowish-red, at first smooth ; they soon become tipped 
with a horny adherent scale, and in certain localities as the dorsal aspect of the 
fingers horny spinous processes may protrude from the apex of the papules. 
On some parts, at an early stage, they may present an appearance like goose 
flesh (cutis anserina), and as they become closely set feel like a nutmeg 
grater. At no time do they show any tendency to become vesicular or 
pustular and when fully developed do not change in size: But the develop- 
ment of new papules between the earlier lesions gradually changes the objective 
appearance by a close aggregation of the lesions, giving the patches an infil- 
trated look and accentuating the furrows of the skin. The disease may, by 
successive development, become generalized over the surface, but usually 
shows a preference for certain localities, as the upper and central portion 
of the back, nape of the neck, sterno-clavicular regions, axillary folds, bends 
of elbows and knees, groins, genital regions, folds of nates, dorsum of fingers, 
palms, dorsum and soles of feet. The eruption may be somewhat modified 
by situation. Thus where the friction of the clothing is greatest, as upon 
the back of the neck and on the hips, the scaliness is least apparent and the 
papules remain comparatively smooth. On the palms and soles where the skin 
is thick the papules may not clearly show, though they always precede the forma- 
tion of thickened scaly patches, which in the course of the disease may become 
the site of fissures ; while on the backs of the fingers where there is no pressure 



202 LICHEN RUBER 

or habitual friction they may remain unchanged for a long time. If the horny 
sheath around the hair is torn away purposely or by scratching, the dilated 
follicle is exposed, but it soon fills again, sometimes with a blackish accumula- 
tion of horny epithelia and sebum, which plug the follicle and rise into conical 
elevations. In most locations the papules tend to increase in number and form 
patches of small or wide extent, which in a variable time lose their papular 
character, and in some regions become converted into uniform scaly areas, 
around which, however, there may be often found isolated papules. Some 
patches may frequently be found yet in the papular stage, when others have 
become completely changed in appearance. 

In the squamous form (lichen ruber squamosus) the degree of scaling may 
vary. Where abundant, it thickly covers the surface with a white, fleece-like 
layer of branny scales, unlike in feature the scaling of any other disease. More 
often the scales, while snowy in appearance, do not entirely hide the exaggerated 
lines bT the skin, or only completely cover a patch for a short time only. 
The shape and extent of the squamous patches vary. Over the spinal region 
of the back, around the waist, over the sternum and on the extremities they 
may occur in oblong or in wide band-like shapes ; in the bends of the arms, on the 
knees and ankles, they may be oval or spindle-shaped : while on the palms they 
may assume annular outlines, and on the trunk and extremities smaller patches 
may become discoid or corn-like in shape. Occasionally, in the latter region the 
scales become larger and thicker, and resemble similar patches of psoriasis. As 
the scales are shed gradually or are rubbed off by the clothing, the affected skin 
presents a striated appearance on a line with the normal folds. This may be 
slight upon the trunk and other parts of the skin not subject to much motion., 
or assume a checked look from cross furrows, but over the joints, buttocks, etc.. 
liable to frequent tension, the wrinkled aspect may be so marked as to totally 
change the objective feature of the disease. 

In the rugous form (lichen ruber rugosus) the thickened skin may form fur- 
rows running in one direction, some merging with adjoining folds, or they may 
be intersected by the less marked lines running at right angles. The scant 
scaliness in this stage leaves the anatomical condition of the surface clearly ap- 
parent, and over extensor aspects of the knee, buttocks, etc.. it may be very 
marked when the part is in the attitude of extension. Like the abundant scal- 
ing of the squamous form, the parallel seaming of the skin is pathognomonic 
of this stage of the disease. 

In the severe forms, the nails take on sooner or later hypertrophic changes, 
either becoming thickened, rough and darker in color, or growing only from 
the matrix show longitudinal hypertrophy with perhaps loss of color. In ad- 
vanced stages the hands may undergo atrophic changes resulting in prominence 
of the joints and impairment of motion. The face may be affected early or later 
in the disease. Papules are not usually apparent upon the face, which may 
first show the onset of the disease by more or less pityriasic scaling, sometimes 
resembling ichthyosis. Occasionally in mild cases the face may escape alto- 
gether. The scalp early, as a rule, becomes covered with a dense scaliness like 




Fig. 59— LICHEN RUBRA 



PITYRIASIS RUBRA PILARIS 

Patient is a woman of forty-three; German by birth; occupation, a dressmaker. 
General health usually good. Disease began nine winters ago on the face, disap- 
peared during the warm months, but with each annual recurrence invaded new 
regions and is now generalized, though worse on trunk and neck. The last four 
years eruption has been less modified in summer. Before onset or with a new 
efflorescence, catarrhal discharges appear, the urine becomes offensive and an oily 
sweat shows on the hands or feet, while most regions are dry and harsh. AVhere 
scales accumulate itching or burning sensations are felt. The lesions consist of pin- 
head sized, reddish, conical discrete papules, except over the right shoulder they 
present a rugose outline, and over the dorsal surfaces of hands and fingers millet- 
seed sized spinous, horny, brownish papules occupy the sites of the hair follicles. 
Seborrhceic desquamation is abundant on face and scalp. White scales cover more 
or less the older patches, while between the scapula? a fleece-like mass completely 
hides the parts beneath. Improvement occurred under the use of natrurn arsen- 
icatum. 



LICHEN RUBER 5408 

a seborrhoea sicca, and the hair loses its normal lustre, but is not destroyed. A 
rare variation of the disease has been described as lichen ruber moniliformis, 
in which the papules occur in beaded lines. G. H. Fox is of the opinion that 
some reported cases of this form were probably cases of lichen planus. 

The three common forms of lichen ruber may be successive stages of the 
disease, which may be found on different parts of the skin at the same time; 
or they may have periods of alternation, interrupted also by more or less gen- 
eral and marked improvement. Again, the disease may be arrested in the 
papular stage, but more often it reaches the squamous type, to persist with 
shifting of location for years, perhaps never developing any pronounced fur- 
rowing of the skin, as in the rugous form. 

Pruritis is often severe, especially in the squamous and rugous stages, 
though not constant, and is sometimes absent or slight in the papular form. 
When the disease is at all general, constitutional symptoms are usually felt, 
such as chilliness, rigors, aching and profuse sweating. These are more apt to 
occur before or with an aggravation of the disease. Then, also, burning and 
itching may torment the patient. Occasionally the general health may be little 
affected for years. One of my patients had been subject to the disease for nine 
years, with one apparent recovery for three months, and many remissions, but 
with each attack progressively extending until every part of the surface had been 
involved, and yet had suffered no material disturbance of general health and 
strength. In most recorded cases, however, watched through their course the 
health has given way to marasmus, exhaustion, etc., which have ended fatally. 

Etiology and Pathology. — Nothing positive is known regarding these. 
Heredity, age, sex or color have no etiological bearing, although, as in psoriasis, 
the disease attacks those who are apparently in good health, more often males 
than females, and the majority before middle life. That it is due to some ob- 
scure constitutional condition or diathesis is most probable from the fact that 
when the disease exists, slight local injury, as a scratch of a pin, may cause the 
appearance of additional lesions at the site of injury. This is said to be the 
immediate origin of the peculiar lesion of lichen ruber moniliformis. A similar 
traumatic origin of new lesions has been observed in lichen planus, psoriasis, 
etc. From the unusual irritability and intense itching, etc., in some cases, Unna 
concluded they were of nervous origin, lichen ruber neuroticus. The patho- 
logical changes that have been found were those incident to inflammation in 
and about the hair follicles, and not peculiar to lichen ruber. Some believe 
with Kaposi that the inflammation of the corium is primary, and that the 
epithelial changes are secondary. Others, with Eobinson in this country, 
that trophic changes (hyperkeratosis) are primary, and that the vascular dila- 
tation, enlarged papillae and other inflammatory changes in the cutis are sec- 
ondary. The corneous layer of the epidermis is thickened by the imperfect 
transformation and multiplication of the cells of the mucous layer. 

Diagnosis. — The mode of development of lichen ruber by small, isolated, 
scale-tipped papules, which do not enlarge but become aggregated into patches 
without any tendency to vesiculation or pustulation, serves early to distinguish 



204 



LICHEN RUBER 



the disease from all other cutaneous eruptions, while the further evolution 
into infiltrated scaly patches with more or less attendant or subsequent ex- 
aggeration of the lines of the skin is sufficiently diagnostic. I have had one 
case of nearly universal papular eczema, some of the papules of follicular origin, 
with a very similar scaliness of the face to lichen ruber, and an unusual dry- 
ness and increase of the natural lines of the skin in some regions, which in 
spots closely resembled the latter disease; but the absence of uniform papules 
and white scales, the presence of blood-capped papules and the occasional oc- 
currence of moist patches, cleared up the diagnosis. Punctate psoriasis and 
isolated papules of lichen ruber might be confounded. The guttate or other 
sized lesions of psoriasis which have grown from the punctate lesions by pe- 
ripheral extension can be nearly always found, whereas the papules of lichen 
are of uniform size and do not enlarge. In the generalized form of psoriasis a 
differentiation from lichen ruber universalis may be difficult. Usually the lat- 
ter has less abundant scaliness, but greater infiltration, and the palms and 
soles are relatively more often and intensely affected than in psoriasis. More- 
over, the latter will usually show some areas of unaffected skin, or patches 
which are undergoing resolution. For differentiation from lichen planus see 
the latter. 

Prognosis. — This is generally unfavorable for permanent cure, if we ac- 
cept the opinion of the majority of dermatologists. The sanguine predictions 
of complete recovery made by Continental observers are believed by others to 
be due to the probable inclusion of lichen planus with lichen ruber. Fn 
England, where the latter form seldom occurs, Malcolm Morris asserts that 
lichen planus is the original type. With that view, the prognosis would be gen- 
erally favorable, because the latter, as seen in this country, is curable, and 
much the most common in occurrence. When the etiology of lichen ruber is 
known, some cases will very likely completely recover under improved methods 
of treatment. 

Treatment. — Looked upon as a probable diathetic affection for want of a 
better conclusion, the first object of treatment of lichen ruber should be to 
attend to the waste and supply of the system, by regulation of quantity and 
quality of food and drink, sunlight, exercise, etc., and the active maintenance 
of the excretions of the body. In other words, physiological living. In the 
earlier stages, a vegetable form of diet is most often indicated, but in the more 
advanced cases, a sustaining mixed diet with abundance of fatty .food, cream, 
butter, cod liver oil, etc., is usually called for. 

Locally the skin needs mechanical protection and relief from the epithelial 
accumulations. The first may be obtained by applications of bland fats or 
oils, used as abundantly and frequently as required to keep the skin fairly 
smooth. The second end, in a measure, is attained by frequent hot baths which 
contain salt, borax, bran, or if the skin is not too much inflamed, friction with 
soap may be emploj^ed. The Turkish bath is excellent for those who can take 
it. The oily applications should follow immediately on drying the skin after 
the bath. Patches of thick scales can be greatly improved by applications of a 



LICHEN PLANUS 205 

three per cent, salicylic acid ointment, or on small flat patches, by the same 
in collodion. Unna's salicylic acid plaster is also useful and convenient for 
the same purpose. Pyrogallol and resorcin may be used in the same manner, 
but cannot be applied to large areas, and present no advantages over the 
preparations mentioned. The scalp may be washed with tincture of green 
soap, dried and well oiled. The foregoing methods and the indicated drug 
will usually modify the itching and other local sensations, especially if care is 
taken to avoid changes of temperature or unusual fatigue. 

■Arsenic or its salts, especially Nat. ars., is more often indicated than any 
other drug, and is to be administered. in the first to third decimal attenuation. 
Merc. cor. is likely to prove helpful in suitable cases. 



LICHEN PLANUS 

{Lichen ruber planus.) 

Definition. — An inflammatory cutaneous disease, characterized by an 
eruption of papules, some of which are flat, angular, shining and umbili- 
cated. These are usually of a dull red color and isolated at first, but may 
coalesce into linear or irregular patches, assume a purplish hue and some- 
times become covered with thin scales. 

The disease is modern in identity, having been first described from the obser- 
vation of about fifty cases by Erasmus Wilson in 1869. It is not an uncommon 
affection in this country. 

Symptoms.— Lichen planus always begins with the development of dis- 
crete papules. The most characteristic become slightly elevated, smooth, angu- 
lar with a pit-like depressed centre; they vary in size from a twelfth to a 
fourth of an inch in diameter, and also vary in color from a crimson 
red to a purplish or lilac hue. Both the. size and color are apt to be uni- 
form in a given case, but may vary quite widely in different cases. As 
a rule, the larger the papules the more angular in shape, some of the smaller 
lesions being roundish in outline. They generally show a tendency to sym- 
metry and a preference for certain locations, such as the flexor aspects of the 
wrists and forearm, the inner side of the knee and the waist above the hips, 
but they may occur upon any part of the external surface, or upon the mucous 
membrane of the mouth. When patches are formed, it is not by enlargement 
of the papules, but by their multiplication, as in lichen ruber. Commonly 
these are small in area, often in lines or irregularly oblong shapes, parallel 
with the length of the limb ; sometimes transversely and less frequently circular 
forms are seen. Occasionally the patches may be extensive, and a large portion 
of the surface may become involved, but the disease is never universal to the 
extent that lichen ruber or eczema may become. Generalized lichen planus is 
not very rare, however, judging by the cases which have been presented or re- 
ported at dermatological society meetings in recent years, in this and European 
cities. The disease may occur in, or assume atypical forms, by a primary ap- 



20(5 LICHEN PLANUS 

pearanee in unusual locations, or with a predominance of conical and convex 
papules. Some departure from the ordinary mode of evolution may occur, 
especially when the eruption is located on the lower limbs, to change the clinical 
course, such as considerable thickening of the diseased skin, lichen planus 
hypertrophicus; papillary outgrowths may take place, presenting a warty ap- 
pearance, lichen planus verrucosus; or dense horny crusts may form, lichen 
planus corneous. 

Although the papules of lichen planus never become directly vesicular or 
pustular, vesicles and bullae have been in rare cases found associated with them, 
and the patches may become the seat of ulceration. 

The course of the disease is variable. Sometimes it may be acute in its 
onset, rapidly spreading and short in course; more often, if acute in develop- 
ment, the course is chronic. Most cases are chronic throughout, and after 
months or 3'ears with or without treatment resolution occurs, papules and 
patches disappear, leaving behind slight atrophic depressions, decided and often 
persistent pigmentation. Earely, severe and widely extended cases may go 
on to failure of health, marasmus and death. 

Etiology and Pathology. — Lichen planus usually begins in middle life, 
though it has been observed in infants under one year of age, and after three 
score and ten years of life. Crocker, who has observed upwards of two hun- 
dred cases, says the most common cause is nervous exhaustion, consequent upon 
strain, deficient or improper food, etc. In common with other investigators 
the editor has noted that a much larger proportion of his cases are among the 
brain workers of the well-to-do classes than among the working classes, who are 
more apt to be poorly nourished. At least four cases, under treatment during 
the last year, gave a neuropathic history. Leredee (Annuals of Dermatology 
and Syphilis, July, 1895) is of the opinion that there may be profound alter- 
ations of the blood which form a pathological link between nervous troubles 
and tbe eruptions; that the latter and the subjective sensations arise from 
changed dermic conditions, due to a toxic substance in the skin or circulation. 
The essential chronic tendency of lichen planus certainly indicates a morbid 
systemic condition (diathesis), whatever may be the contributing factors which 
lead up to it and its inflammatory lesions. The latter (papules) are found 
chiefly at the mouth of the sweat ducts (the glands themselves are seldom in- 
volved) and appear due in the first place to a cellular infiltration in the upper 
part of the corium, pushing outward the little changed rete, which subse- 
quently may, by proliferation of its cells, become thickened downwards by 
interpapillary growths, and upwards to form the chronic papules. A char- 
acteristic feature is the marked definition of the affected papillae and sub- 
papillary layer from the normal tissue beneath. The corneous layer may 
be unchanged or even thinned, except at the mouth of the sweat ducts, where 
a horny plug forms and constitutes the minute central depression of the char- 
acteristic lesions. The hair follicles and sebaceous glands are not affected. 

Diagnosis. — In typical cases no difficulty will be found in recognizing the 
disease. The flat, angular, smooth, shining, umbilicated and purplish papules 






LICHEN PLANUS -"< 

axe never Been is any other disease. Some one or more of these characteristics 

of the papules may be lacking, however, and when rather thick, scaly patches 
are formed, the disease may be mistaken for psoriasis or chronic eczema, but 
even in those cases nearly always there can be found near by some evidences 
of the characteristic lesions. The author had seen one case situated on the 
extensor aspect of the arms, which simulated psoriasis very closely, but the 
history of the papular origin, the thin, scant scales, purplish color and stains 
at the site of resolved lesions, served to distinguish it as lichen planus. Chronic 
papular eczema may sometimes exhibit isolated, flatfish, smooth papules, but 
they are never angular or depressed in the centre. On the other hand, the 
eczema papules are likely to be excoriated, differently located, and may be- 
come moist unlike lichen planus lesions. 

Lichen ruber is a rare disease as compared with lichen planus; its papules 
are conical, mostly sittiated at the hair follicles, and when aggregated in patches 
may become covered with abundant scales; it usually pursues an irregular 
course to a fatal termination. These and other differences will enable one 
generally to make a diagnosis by exclusion. It is only when there is a pre- 
dominance of convex papules in lichen planus that difficulty may be experi- 
enced. Even then attention to the clinical history wall usually remove any 
doubt. In typical cases of lichen planus the "pathognomonic gray points and 
striae" said to sometimes dot or mark the red ground color of the papules may 
be of diagnostic value. Louis Wickham says the gray workings can often be 
found in typical forms, and they may be regarded as pathognomonic. 

Prognosis. — The health suffers little, as a rule, from lichen planus. Itch- 
ing may cause much discomfort, and the eruption persist through a chronic 
course, even under treatment, but finally recovery follows, sometimes spontane- 
ously, perhaps unexpectedly. 

Treatment. — From the probable diathetic and neuropathic nature of this 
affection, it is apparent that diet, exercise, clothing, rest and all other means of 
physiological living should be carefully studied. Changes of scene, of climate 
and of occupation may benefit. Tonics (non-alcoholic) are often indicated. 
For this purpose the milder high frequency currents applied along the spine 
will benefit. Protection and relief of pruritus are demanded in most cases. 
The remarks about bland oils or fats and alkaline baths made under lichen 
rubra apply in case of lichen planus. Liquor carbonis detergens, one to fifty 
per cent, (gradually increasing), in solution or ointment, or carbolic add, 
two per cent., with boric acid, ten per cent., used in the same manner, may 
be used for the itching. The editor prefers calamine, two drams, glycerine and 
rose water, each a one-half ounce to three ounces of milk of magnesia, as a 
topical application for adults. Local pathogenetic treatment may be needed 
for chronic infiltrated patches. Salicylic acid (ten to twenty per cent.) oint- 
ment, or fifty per cent, solution of hydrogen peroxide may be found useful. For 
the same purpose the Rontgen rays are serviceable. Exposures numbering 
from three to twelve, bi-weekly, using the same technique as suggested in the 
treatment of psoriasis, will relieve the pruritus, absorb the papules and cause 



20* PARAKERATOSIS VARIEGATA (UNNA) 

gradual resolution, accompanied by desquamation and in a few instances fol- 
lowed by pigmentation. Phototherapy bas been recommended for localized 
types of this disease. For the internal remedy see indications for Anacard., 
Arsen., A. hyd., A. iod., Berb., Kali carb., Ledum,., Mangan., Merc, vivus, M. 
cor., Nat. mur., Nux vomica. 



PARAKERATOSIS VARIEGATA (UNNA) 

It can hardly be said with certainty that this is a distinct disease. First 
knowledge of it rests upon the observation and study of two cases which 
came to Unna's clinic at Hamburg. Since then about a dozen cases have been 
reported resembling more or less closely the first named. Most of these were 
observed on the Continent, several in England and two by J. C. "White in this 
country. Pollitzer, who was a pupil of Unna's, describes the eruption as fol- 
lows f~""The greater part of the body was covered with a red exanthem, which 
formed an irregular network, leaving free, small, irregular, sunken patches of 
normal skin. The affected portions were but slightly raised above the normal 
surface; their borders were sharp, their cuticular areas but slightly marked, 
their surface affected by a fine lamellar desquamation, under which the patches 
had a peculiar waxy, reddish hue; their color was deeper on the more depen- 
dent portions of the body, but was not strictly uniform even for the same 
region, varying from yellowish-red to bluish-red. The larger patches appeared 
to the touch decidedly infiltrated, like an erythema papulatum ; the smaller re- 
sembled recent lichen planus papules.'' The second case was very similar to 
the first, except that the color of the eruption was paler. Both were men other- 
wise in good health, and aged respectively thirty-three and twenty-seven. In 
one the disease had existed for four years, and in the other for seven years, with 
little change in appearance, and without subjective sensations. The cases 
proved obstinate to treatment, but finally yielded to free use of pyrogallic acid 
externally and large doses of dilute hydrochloric acid internally. 

Eare cases presenting similar lesions have been variously named as follows : 
erythrodermie pityriasisque en plaques disseminees (Brocq) ; lichen variegatu-s 
(Crocker) ; dermatitis variegata (Boeck) ; dermatitis psoriasiformis nodu- 
laris (Jadassohn) ; lichenoid eruption (Neisser) ; pityriasis lichenoides chron- 
ica (Juliusberg). Hyde prefers to class all of these conditions under the 
general head of psoriasiform dermatoses. 

The description and history of these cases show a certain resemblance to 
lichen planus, and it is possible they may have been anomalous cases of that 
disease. Physiological treatment and minute doses of arsenic would seem 
indicated. 



KERATOSIS PILARIS '209 

KERATOSIS PILARIS 

(Pityriasis pilaris; Lichen pilaris.) 

Definition. — An accumulation of horny epithelia, which form small 
papules and plug the orifice of the hair follicles, usually situated on the ex- 
tensor aspects of the extremities. 

Symptoms. — The papules are convex pin-head size, of the same color as 
the normal skin, or grayish, even blackish, from deposits of dirt. Occasionally 
they have a reddish tinge, lichen pilaris, a term no longer used to designate 
non-inflammatory papules. A hair may sometimes be found piercing the papule, 
but more often it is broken off or imprisoned within. If a papule is picked off, 
the depressed orifice of the follicle is seen. The intervening or adjacent skin 
may be normal in color, but is usually dry and sometimes scaly, as in mild 
ichthyosis. 

The location of the disorder is commonly symmetrical on the extensor and 
outer surfaces of the arms and thighs, but is occasionally seen upon the trunk, 
and in rare generalized cases may occur, late in order, upon the face. When 
the papules are thickly set they give a nutmeg-grater feel to touch, but the 
number of papules and the extent of their distribution vary greatly, and 
sometimes are scarcely noticeable. Well-marked cases of some duration may 
show among the papules points simulating punctate scars, the site of resolved 
lesions. 

Etiology and Pathology. — Some authorities attribute a proportion of 
cases to long continued neglect of bathing the skin. It is not unusual to find 
a harsh condition of the surface in those who bathe infrequently, but in none 
of the cases of keratosis pilaris which I have seen could want of cleanliness be 
assigned as a cause. In some, the proclivity had apparently existed from in- 
fancy, but without any impairment of health or vigor ; in all it began during 
the formative period of life, i.e., before the twenty-fifth year. In vigorous 
patients, an inherited predisposition would seem causal, while in those under- 
going prolonged arsenical treatment or in those cachectic subjects who de- 
velop keratosis pilaris the cause can readily be seen. A few observers believe 
it a physiological excess rather than a pathological development, but inasmuch 
as the same condition is most pronounced in association with some cases of 
ichthyosis it is probably due to a like or the same constitutional tendency, 
though it is proper to say that some view the latter disorder as a deformity 
rather than a disease per se. The pathological cause seems due to an excessive 
cornification of the epithelia of the outer portfion of the pilo-sebaceous duct, 
which, forming a papular-like mass, occludes the orifice of the hair follicle. If 
the mechanical pressure is sufficient, the superficial blood-vessels of the corium 
may become congested, producing the tinge of redness sometimes seen. This 
periglandular inflammation has been demonstrated by Giovannini, who claims 
that it is marked in a few cases. Atrophy of the hair and sebaceous struc- 
tures may occur, leaving minute scars, or secondary pustular inflammation may 
rarely contribute to the same end. 



210 KERATOSIS SENILIS 

Prognosis. — As a rule, all cases of the disorder can be cured by proper 
attention. 

Treatment. — This is very simple and chiefly mechanical, to meet mechan- 
ical conditions which exist in all cases. It consists in a daily cold fresh 
or salt water bath (using coarse toweling in place of a sponge) and followed 
by frictions with a very rough towel or flesh brush. Occasionally, in children, 
a light inunction of simple fat or oil subsequent to the bath is beneficial. This 
treatment should be continued for months or even years. For immediate use, 
the hot bath with soap may be necessary, twice a week, followed by the thor- 
ough application of lanolin or some simple oil or fat. If no departure from 
good health is shown by symptoms, a constitutional remedy should be given 
which is known to produce hyperkeratinization of the epidermis, or desquama- 
tion of its surface. Among drugs see indications for Ars. alb., Cal. carb., 
Nat. mur., and Staph,. 



KERATOSIS SENILIS 

The more or less general atrophy of cutaneous tissues which occurs in old 
age may sometimes have mingled with it local or general tendency to hyper- 
trophic alterations. Among them keratosis is sometimes a feature. This may 
be slight, amounting to only a dryness and roughness of certain parts, as the 
back of the hands, the feet and on the face, or a wider extent of surface may 
be affected; rarely the whole body, which in severe cases is sometimes covered 
with horny, branny adherent (rarely greasy) scales. With these may be seen 
other changes of pigmentation and warty formations. The keratosis may be 
limited to the outer covering of verrucous growths, which are not uncommon 
in the aged, or connected with seborrhoeic patches, forming greasy adherent 
plates. 

The treatment of these surface conditions of the aged consists in correct- 
ing, so far as possible, any general departure from health by physiological and 
other methods, and in aiding to improve the appearance and comfort of the 
skin by tepid baths, gentle frictions and moderate applications of bland fats. 
In trying to foresee the fxiture course of these cases, the liability of cancer 
originating in the abnormalities of the skin of the aged should not be forgotten. 
In a number of cases in which epitheliomatous changes had begun, Hyde 
reports that the Rbntgen rays caused a complete disappearance of the hyper- 
keratosis. Such remedies as Baryta acet.. B. carb., and Cal. phos. are often 
indicated. 







Fig. 60.— KERATOSIS OF THE SOLE 

KERATOSIS PALMARIS ET PLANTARIS 

Subject is a fat married woman of forty-five; a housekeeper, living comfortably. 
The disorder began two years ago with dryness of the palms and soles, which grad- 
ually became thick, hard and stiff. Later the soles presented a worm-eaten appear- 
ance from irregular cracks and separation of the corneous plates. During this time 
the patient has increased in weight and suffered from dull headache and vertigo. 
General aggravations have followed from eating pork, and relief from the open air. 
Bathing with cold water gives local relief (from soakage of water), but is followed 
by a greater aggravation. Nearly cured by antimonium crud., sixth decimal. 




Fig. 61— KERATOSIS OF THE PALM 

KERATOSIS PALMARIS ET PLANTARIS 

Patient, same as in Fig. 60. The whole palmar surface is hard and thick like 

sole leather. 



KERATOSIS PALMARIS ET PLANTARI8 '^H 

KERATOSIS PALMARIS ET PLANTARIS 

(Tylosis palma et plantcej Ichthyosis palmaris et plantaris; Keratoma, etc.) 

Definition. — A conversion of the epithelia of the palms and soles into 
dense, corneous plates, unconnected with intermittent pressure from occu- 
pation. 

Symptoms. — The disease occurs symmetrically both on the palms and soles. 
Occasionally the feet alone are affected, and more infrequently still the hands 
nun be involved without tbe feet. It may be congenital or acquired. The dis- 
ease may begin with an unusual dryness of the palms or soles, and no signs 
of sweat appear while the disease lasts. More often there is an excess of mois- 
ture or hyperidrosis, which may continue to appear at times throughout the 
course of the disease. When seen by the physician, the surfaces involved have 
usually become partly or completely covered with a firm, leathery, thickened, 
horny epidermis, which, if moderately smooth, may resemble the finished side 
of sole leather. Sometimes the surface is seamed, fissured and uneven, or 
worm-eaten in appearance. On the soles the skin in the hollow of the instep 
is exempt from the extreme effects of the process, though often dry and ex- 
foliating. The sides of the heel and other borders of the sole may be more 
or less involved, but in less degree than the bottom of the foot. Usually there 
is some erythematous redness without heat at the margin of the more thickened 
epidermis, and this may extend well onto or over the dorsal aspect of the feet 
or hands, erythema heratodes. When the erythema and other changes occur 
in patches, it was called by Besnier Jceratodermia erythematosa symmetrica. On 
the back of the hands I have seen the extensor surfaces of all the fingers and 
distal half of the hand everywhere deeply red, and at times thickened so that 
cracks through into the corium occurred from tension in closing the hands. Even 
without the involvement of the dorsal surfaces, the hands are rendered stiff 
and tense by the leathery thickening of the palmar surface of hand and fin- 
gers. The skin of the wrists adjacent to the palms often shows the effect of the 
process by an exaggeration of the normal lines and the addition of new ; while 
over the palm and fingers some of the natural lines may be obliterated or over- 
shadowed by linear folds running in different directions, especially in a longi- 
tudinal direction on the fingers. In the smooth, leathery form in which the 
surface is habitually dry, the thickened epidermis is readily softened by a soak- 
age in water and the abnormal lines temporarily disappear, but the condition 
is subsequently aggravated in every way. One or more of the nails may be 
lifted away from the nail-bed by masses of accumulated epithelium at the 
borders, and the body of the nail roughened and thickened by the perverted 
cornification. Occasionally in cases which last for some time the coriaceous 
plates may be spontaneously shed_ to re-form after a longer or shorter interval. 
In rare instances variable disturbances in nutrition of the hair on the forearms, 
ankles or legs have been noted, either by an abnormal growth of hair or a com- 
parative absence of hair. In the affected palms and soles there is seldom any 
disturbance of sensation. 



212 KERATOSIS PALMARIS ET PLANTARIS 

There is commonly diminished sensitiveness to touch, and when the hands 
or feet are much used they may become sensitive to pressure, so that occupa- 
tion with the hands or walking may be painful. There are often found 
varying general symptoms, such as headache, vertigo, etc., but no constant 
characteristic constitutional disturbances, except, perhaps, a slowness of the 
pulse in a proportion of cases, and then the general health seems little 
affected. 

Etiology and Pathology. — Heredity has been found as a predisposing 
cause in a number of cases, in one instance extending through generations. It 
is often congenital, though in such cases the disease may develop very gradually. 
In acquired cases excessive sweating (hyperidrosis) is a common antecedent 
and attendant condition. Some cases have been attributed to the use of 
arsenic internally. While nothing positively is known regarding the real etiol- 
ogy of this unusual disease, it is probable that the underlying cause is con- 
stitutional and gives expression to its peculiar features through the trophic 
nerves, or it is possible that the central nervous system may be the seat of the 
pathological cause. Pathological changes consist in a normal, though exces- 
sive, cornification of all layers of the skin. Vomer found no signs of inflam- 
mation. The condition is not dissimilar, microscopically speaking, to that 
found in callosities due to intermittent pressure. 

Diagnosis. — The distinctive features of keratosis of the palms and soles 
are its comparatively rare occurrence, symmetrical development, more or less 
horny thickening of the epidermis and the absence of any sign of inflamma- 
tion. With these in mind there will be no difficulty in recognizing the dis- 
ease. 

Prognosis and Treatment. — In congenital and inherited cases complete 
recovery is rare, but the skin may be rendered soft and the patient comfortable 
by continued treatment. For all other types the prognosis is favorable for 
ultimate recovery, which may he often slow, but is sometimes rapid when the 
therapeutic indications are clear. When the latter are found to exist, no local 
treatment beyond cleanliness is needed. In many cases, however, in the ab- 
sence of symptoms, a remedy has to be based on the pathological condition, and 
local mechanical measures are needed to aid the cure. The thicker corneous 
plates may be carefully shaved off with a sharp knife or razor, and fatty or 
oily applications made to soften and loosen the horny tissue. This can be fol- 
lowed by daily friction with ordinary or green soap and hot water, and re- 
anointing with simple fat. Eemoval of the thickened tissue may be facilitated 
by incorporating with the fat (lard) five to ten per cent, of salicylic acid; 
or on the soles Unna's salicylic acid plaster may be worn in the same way as 
directed for squamous eczema of the soles. 

The Rontgen rays occupy an important place in the therapeutics of this 
condition. Almost uniform good results have been reported and in a number 
of instances one to two years have elapsed without a recurrence. Usually ten 
to twenty exposures are necessary, varying from four to ten minutes : the tube 
being at a distance of six inches. 



ICHTHYOSIS 213 

The general health should be inquired into and all indications met by 
physiological and pathogenetic means. For choice of the latter see indications 
for Ant. crud., Baryta carb., Col. fluor., Curare, Hydrocot., Nat. mur. and 
Sulphur. 



ICHTHYOSIS 

(Fish skin disease; Xerosis; Xeroderma ichthyoides; Ichthyosis vera.) 

Definition. — A congenital affection of the skin characterized by ex- 
treme dryness, roughness, more or less scaling of the surface, and some- 
times by the development of warty looking growths. 

The disease or deformity, as it is sometimes called, is not uncommonly 
seen in some form. These forms are fairly distinct in degree or type, and are 
known as xerosis or xeroderma, ichthyosis simplex and ichthyosis hystrix. The 
first two are general and really variations in degree, and often exist together 
on different parts of the skin; while the third is clinically distinct and more 
localized. All begin in early infancy and are believed to be congenital in 
origin. 

Symptoms. — The mildest form, xerosis, is the most common. In this 
the skin presents a dry, dirty, furfuraceous look, and feels harsh to the touch. 
The scales are turned up slightly at the edges, quite adherent, exaggerating 
the natural lines of the skin and contributing to its thickened appearance. 
While the whole surface is usually dry and darker in color, the most marked 
changes are commonly found on the extensor surfaces of the extremities, trunks 
and about the buttocks. Here also in some cases are found numerous scaly 
papules, or the condition which has been described as keratosis pilaris, and 
which may greatly add to the rough condition of the surface. The state of 
the skin is apt to be worse in cold weather, sometimes nearly disappearing in 
warm seasons, and in the mildest cases may, after a time, only show a lack 
of softness, and a tendency to crack, due to diminished secretion of sweat and 
sebum. Notwithstanding this period of improvement, the condition never quite 
disappears without treatment for many months at a time, and unless cured 
before is, in mature life, likely to become worse, though it may never pass into 
the more severe forms. 

In ichthyosis simplex the changes in the appearance of the surface of the 
skin are more marked and characteristic on certain regions, while others are 
less changed or exhibit the same appearance as in xerosis. Like the latter, 
the most pronounced features of the disorder are seen upon the extensor aspects 
of the extremities, about the buttocks and shoulders, though in severe cases the 
marked characteristics may be widely extended. These consist in the early 
formation, following a dry, roughened surface, of large, angular, papery, cor- 
rugated scales, varying in color from a pearly white to a dirty white, rarely 
a greenish or blackish hue. The scales are firmly adherent with detached shin- 
ing edges, which mark the interspaces between the scales and give to the sur- 



214 ICHTHYOSIS 

face a tesselate pavement-like appearance, or resemble the skin of a fish, from 
which the name is derived. The most marked scaling is usually on the anterior 
surface of the legs from the thigh to the ankle. The flexures show the least 
change, and the palms of the hands and soles of the feet may be little affected 
beyond a hardening of the epidermis, giving to the surface a smoother look 
from obliteration of the smaller lines. So-called cases of ichthyosis palmce 
are usually forms of keratosis or callus formations. On the head the hair 
becomes dry and lustreless, and the surface of the scalp more or less branny ; 
while the skin of the face is less scaly, it is often red, thickened, ecze- 
matous and fissured, especially in cold weather. In severe cases contraction of 
the skin may cause atrophy of the lobe of the ears and ectropion. As a rule, 
the disease is worse in cold seasons and better in warm. Barely the period of 
aggravation may be the warm part of the year, probably when the perspiratory 
function is no longer sufficient to aid in equalizing the systemic temperature. 
Fully deyeloped cases seldom show sensible perspiration on the surfaces in- 
volved ; frequently, however, the flexures, axillae, palms, soles and face may be- 
come moist in warm weather or during exertion, and rarely it may amount to a 
hyperidrosis of the palms, soles, etc. In middle life, there may be no apparent 
secretion of either sweat or sebum, yet the scales or horny plates often have a 
greasy quality and fat can then be dissolved out of them. The local sensations 
of itching or burning are sometimes complained of, especially when the skin 
is uncovered, but unless the disease is severe or the skin eczematous such symp- 
toms are usually mild or absent. It is to be borne in mind, however, that the 
ichthyotic skin is sensitive to external cold, etc., and very subject to eczematous 
disturbances or other intercurrent inflammations. Individuals with xeroderma 
may be plump or even stout, but with well-marked ichthyosis simplex they are 
always thin, without in most cases suffering much impairment of general 
health. 

Unusual clinical variations in the objective features of the disorder have 
led to the use of fanciful names from time to time to designate them. Some 
of them are introduced here because they still occur in works on dermatology, 
though nearly all agree that they ought to be obsolete, as of no value : 

Ichthyosis nigricans indicates a condition of coloration observed in the 
older horny scales or plates, of a yellowish green or blackish hue, and is not 
very uncommonly seen on the anterior surface of the legs. When the adherent 
plates resembled the skin of a serpent, it was called ichthyosis serpentina, or, 
if more dense, like a crocodile's hide, ichthyosis sauroderma. Ichthyosis ?iitida 
stands for a peculiarly marked transparent and shining appearance produced 
by the detached portion of the scales, while the predominance of scales de- 
pressed in the centre and resembling a shield in outline was designated as 
ichthyosis scutulata. 

Ichthyosis congenita (ichthyosis fcetale, harlequin foetus, ichthyosis seba- 
cea, cutis testacea) is employed to designate cases which are born ichthyotic, 
in distinction from most cases which develop in the first weeks or months after 
birth. A score or more of cases of rare conditions of the skin found at birth 




Fig. 62.— ICHTHYOSIS SIMPLEX 



Patient, a boy of ten, of American parentage. The entire skin is abnormally dry, 
and since birth a fish-scale appearance of the extensor surfaces of the thigh, arm 
and trunk has been noticeable. This condition is always better in the summer, 
from free sweating or from frequent oil baths, and is always worse in the winter or 
when neglected. Petroleum, sixth decimal, is given internally, while sweet oil is 
applied locally. 




Fig. 63— ICHTHYOSIS HYSTRIX 

Patient is a boy of fifteen, in good health aside from the cutaneous disorder. A 
scaly condition of the skin developed before he was two years old, a few weeks after 
a first vaccination, his mother states, and persisted in a classical course until five 
months ago. When with an aggravation of the usual features there appeared on 
the flexor surface of the knees, thighs, part way down the legs and on the inner aspect 
of the thighs, brownish, warty, corrugated lesions, dry and rough to the touch, very 
like the sensation felt from rubbing the hands over the bark of a tree. These sec- 
ondary growths faded away rapidly under thuja, third decimal. The illustration is 
from a photograph made two weeks after the drug was first given, and when more 
than half of the warty lesions had disappeared. 



ICHTHYOSIS 215 

have been reported under the above terms: much confusion exists as to their 
identity. According to Kaposi .some reported cases are such as lie describes 
under ichthyosis sebacea or cutis testacea, as true cases of seborrhoea of the 
new born, and distinct from ichthyosis congenitalis. 

Acquired ichthyosis beginning after infancy is rare, and its occurrence is 
doubted by some authorities. There seems to be no more ground for reject- 
ing these rarer cases from the category of ichthyosis than there is for as- 
suming that cases beginning late in infancy are necessarily congenital. Cases 
have been reported as originating between the twelfth and seventy-sixth year; 
the latter by Crocker, who speaks of it as "a typical ichthyosis of the ordinary 
form." The same careful observer has more recently described (British Jour- 
nal of Dcni'utology, July, 1895, p. 217) a well-marked case in a man of 
seventy-lour, which had gradually developed during the previous ten years. 

Ichthyosis hystrix is a rarer form which sometimes exists in association 
with some manifestations of xerosis or ichthyosis simplex, but may occur with- 
out signs of the latter. It is never generalized or symmetrical, often has definite 
limitations at the median line on the trunk, but more commonly occurs in 
transverse lines on the body or in longitudinal lines on the extremities; the 
face is rarely involved. The lesions consist of reddish-brown, greenish or 
blackish growths, which may be of pin-head size with a horny cap, and project 
only slightly above the surface; or they may be in larger, warty, vertically 
striated, horny masses protruding half an inch or more from the surface of 
the skin. The so-called "porcupine men" who have been attractions at shows 
are extreme instances of this disorder. If the horny coverings of the growths 
are forcibly pulled off, bleeding points and hypertrophied papilla? are brought 
into view. On the palms or soles or other parts exposed to much friction or 
pressure these formations may give rise to much inconvenience and pain, 
though in these exposed locations, as elsewhere, they may be painless, and 
may be spontaneously or periodically shed. Papillary growths are sometimes 
found on the mucous surfaces of the mouth unconnected with so-called ichthy- 
osis linguce, now known to be of a different origin. Earely these have been 
noted in association with this affection, lack of complete development of the ear, 
mental weakness and other defects. Ichthyosis hystrix may be present at birth, 
but more commonly, like other forms, it appears some weeks or months later. 

Etiology axd Pathology. — The causes are not known beyond the con- 
genital origin (that is, nearly all cases begin in early infancy), and sometimes 
a more or less marked direct, interrupted or lateral heredity. The sexes are 
about equally affected, though Kaposi mentions a family in which all five 
sons of an ichthyotic mother were affected, and all three daughters escaped. 
Crocker also speaks of an ichthyotic father with a family of seven daughters 
and three sons, the latter being the youngest, in which, beginning with the eld- 
est daughter, each alternate child, including the oldest son (four girls and 
one boy) were affected with the disease. The rarer acquired cases, and some 
of the hystrix variety apparently located on the line of the nerve distribution, 
may have a neurotic origin ; but in general it can only be said that the skin 



216 ICHTHYOSIS 

lesions of ichthyosis depend on a persistent proclivity to definite types of cutane- 
ous disorder, whether originating before or subsequent to birth. The patho- 
logical cause is essentially a hypertrophy of the epidermis and the papillary 
layer of corium. However, the rete is often thinned and the papillary hyper- 
trophy is often more apparent than real, the elevations being due to a dipping 
down of the horny layer with the resulting compression and elongation of the 
papillae which often atrophy. Only slight evidences of an inflammatory na- 
ture are found in the cutis. 

In well-marked cases of the hystrix form the papilla? are enormously 
elongated, with supra-imposed cones or caps of dense, horny epithelium. 
Kaposi has noted that this condition does not differ from that present in old 
warts. 

Diagnosis. — Commonly this disorder is easily distinguished from all others 
by its predominant feature of origin in early infancy, together with, in 
xerosis, the rough, dirty looking and deeply lined skin; in ichthyosis simplex, 
by the additional pavement-like scales and favorite sites of distribution ; ichthy- 
osis hystrix, by the warty growths, with a tendency to linear distribution. 
Chronic papulosquamous eczema may rarely resemble xeroderma with or 
without intercurrent eczematous inflammation. One such case of eczema 
presenting a similar dry, rough and deeply lined skin on several regions 
of the body, I have seen in consultation. The history, origin long after in- 
fancy, the presence of papules, excoriations, etc., served to determine its 
nature. Prurigo, which often begins in infancy, may have a later like- 
ness to ichthyosis, but in such cases the history and evidence that the infil- 
tration, roughness, etc., of the skin are due largely to mechanical irritation of 
the surface from scratching will be quite apparent. Xeroderma (Angioma) 
pigmentosum is always most marked on the exposed parts of the skin, as the 
face, neck and hands, while the reverse is true of ichthyosis. 

Prognosis. — The fact that cases of ichthyosis have recovered indicates that 
the prognosis of mild forms is not entirely hopeless. Nearly all, however, 
while they may be made comfortable and continue in good general health to 
old age, cannot be promised permanent cure. 

Treatment. — The skin of the ichthyotic requires mechanical protection 
in connection with cleanliness. The daily bath is beneficial to all; the water 
may be made unirritating to the dry skin by a small quantity of salt, bicar- 
bonate or biborate of soda, or by bags of bran immersed in water, etc. If 
the scales are found to contain fatty matter, soap may be used in the bath; 
usually soap is contra-indicated. Immediately after the bath the affected 
skin should be oiled with any simple fat, choice being determined somewhat 
by the means of the patient. Lanolin and sweet almond oil (one to six) is 
the most elegant application, biit fresh (or benzoated) lard, sweet oil, cod liver 
oil, mutton tallow, and all unirritating fats serve the purpose. If the whole 
skin is involved, these daily anointings require some expenditure of time, but 
the reward in comfort and improvement is ample compensation to most pa- 
tients. When the means of a patient permit, change in the cold season to a 



SCLEREMA NEONATORUM 217 

warmer climate is generally beneficial, or if possible change of permanent resi- 
dence to a climate conducive to the comfort of the skin. Warm weather and 
moist atmospheres are the most suitable. In the hystrix variety, steam, hot- 
air, alkaline and sulphur baths together with salicylic acid ointment or plaster 
(ten to twenty-five per cent.) may be needed to remove the scales. Annoying 
projections may be removed by simple excision or by the Paquelin knife. Inter- 
current diseases of the skin (eczema, etc.) should be treated on indications 
furnished by the whole pathogenesis, and any general or local disease or con- 
dition should receive attention so far as practicable by physiological and patho- 
genetic methods. As possible internal remedies see Alumina, Cal. fluor., Sepia 
and Thuja. 



SCLEREMA NEONATORUM 

{Induration of the cellular tissue of the new born; Sclerema of the new born; 
Scleroderma neonatorum; Indurato tela cellulosa.) 

Definition. — A characteristic induration of the skin, either congenital 
or occurring soon after birth. 

Symptoms. — This affection, first described by Underwood in 178-i, and 
which is now recognized as distinct from scleroderma or oedema of the new 
born, may be present at birth, or develop during the first few weeks of life, 
seldom after the first month, but rarely later. The strictly congenital cases, if 
not still born, die within a few days after birth. The disease begins, as a rule, 
in the lower limbs and extends upward over the thighs and back, thence to the 
chest, and over the remaining surface of the skin, becoming universal in four 
or five days. Exceptionally it may begin on the face and spread downwards, 
and at whichever point or origin the morbid process may be arrested when only 
a smaller or greater part of the surface is involved. The changes in- the skin 
produce a hard, resisting surface, which cannot be gathered into folds or pitted 
on pressure. At first whitish or a dirty yellow in color, it takes on a deeper or 
livid hue; the natural wrinkles are obliterated, and the surface looks or feels 
smooth, polished, firm, cold and marbleized. Even the face may be so im- 
mobile as to render the child unable to move the jaw, or open the mouth in the 
attempt to nurse at the nipple; frequently the infant lies motionless, with a 
hardly perceptible expansion of the chest, closed eyes, expressionless features, 
and in so rigid fixation of the whole body that raising it with one hand does not 
change its outline. The pulse and respiration may be less than one-half their 
normal frequency, and the temperature several degrees below normal, sinking 
lower as vitality is exhausted and death approaches. Fatal cases rarely live a 
week. Sometimes the disease is arrested, the temperature, pulse and respira- 
tion rise, and recovery may follow. 

Etiology and Pathology. — The real cause or causes are unknown. 
Whether a remote syphilis or some other constitutional vice transmitted from 
immediate or further removed generations predisposes to it or not, the disease 



218 (EDEMA NEONATORUM 

apparently maj- begin from any temporary cause which lowers vitality and the 
cutaneous circulation, such as lack of protection of the new born from cold, 
etc., after birth, affections of the digestive organs, pulmonary and cardiac dis- 
orders. Underwood and Parrot consider it "an institution disease, often in 
overcrowded rooms and associated with bad hygiene and improper feeding." 
Whatever the predisposing causes may be, the immediate one is a retardation of 
the circulation in the cutaneous capillaries. As to the pathological changes in 
the skin which follow a loss of vitality in the new born and result in sclerema, 
there is no unity of opinion. Some, with Langer, look upon it as a fat (stearine) 
infiltration and solidification ; the latter asserting that the fat of the new born 
child is solid at a bodily temperature of 89.6° F., while that of adults solidifies 
only below 32° F. Others, with Parrot, believe that the solidification of the 
dermal tissues results from drainage of the watery fluid from the skin, as a 
consequence of diarrhoea, etc. Ballantyne holds that the disease is due to an 
overgrowth of connective tissue, leading to atrophy of the fat-cells and that 
the condition is a tropho-neurosis. See Prognosis and Treatment under 
oedema neonatorum. 



CEDEMA NEONATORUM 

{(Edema of the new born.) 

A hardening of the skin of the new born from subcutaneous oedema was 

formerly confused with sclerema. The disorder begins in the lower extremities 
in the first week of life, or it may show at birth in the premature born. The 
legs, which are cold, livid and swollen, may be only affected: more often the 
oedema spreads up the thighs to the genitals, appears in the hands and arms, 
and sometimes becomes nearly universal. Sometimes the swelling may begin 
on the back or in the face, but the latter never becomes inflexible, as in scler- 
ema. Like most dropsical conditions, the swelling is worse in the most 
dependent parts, as the posterior part of the calves and thighs. The surface 
pits on pressure, or is doughy and is only depressed by long pressure. The 
skin, however, can be pinched up and the marble-like hardness and appear- 
ance of sclerema is absent. The bodily temperature is usually lowered, and 
in severe cases the pulse and respiration are slowed, the child is too drowsy 
to nurse, and a fatal end may be reached in a few days, with or without} 
complicating renal or cerebral disturbances. Exceptionally reactions may 
occur, with high fever, and an icteric hue of the surface may take the place 
of the livid color in fatal cases. On the other hand, when the disease is not 
completely developed or too extensive the symptoms may abate, the skin be- 
come softer and recovery gradually follow. 

Etiology and Pathology. — The predisposing causes are the same as 
noted in sclerema, to which may be added premature birth. The pathological 
causes, so far as known, however, are unlike the latter. A thrombus in the 
femoral vein was found in one instance, and Ballantyne. who found a nephritis, 



(EDEMA NEONATORUM 219 

thinks it may arise from renal, pulmonary or cardiac disturbances. On ex- 
amination, there will be found an effusion of yellow serum into the sub- 
cutaneous tissue and the fat appears granular, dense and yellowish. 

Diagnosis. — The age of occurrence will distinguish both sclerema and 
oedema neonatorum from other affections attended with induration of the skin. 
No case of scleroderma has ever been recorded as beginning before the second 
year of life. Sclerema and oedema of the new born have many associated con- 
ditions in common, but in cutaneous development they are sufficiently unlike 
as to be easily recognized one from the other. The former is more general, is 
little influenced by gravity, the skin is denser, does not pit on pressure, and is 
usually attached to the parts beneath; the stiffness of the face and body may 
be so pronounced as to render them nearly or quite inflexible even when the 
latter is raised on one hand. On the other hand, oedema is more apt to be 
limited, is worse or may be limited to the most dependent parts; the affected 
skin is not so dense, usually pits on pressure, is not attached to the subjacent 
parts, and is seldom markedly immobile. 

Prognosis. — Partial cases of either disease may recover. In favorable 
cases sclerema may make the most rapid recovery, but in general its prognosis 
is more serious than that of oedema. 

Treatment. — Measures to increase and maintain bodily temperature and 
the circulation of the blood are indicated in both diseases. An incubator can 
be used, if convenient, for the purpose of furnishing artificial heat, or hot 
flannels, cotton, wool, and hot-water bottles may be carefully emploj'-ed. Fric- 
tions directed from the extremities toward the heart with warm, nutrient oils or 
fats may be of service. If the infant is unable to nurse, predigested milk or 
other liquid animal food may be fed by the mouth, or if unable to swallow, a 
rubber tube and syringe or stomach pump can be used to introduce nourishment 
into the stomach. Indicated drugs can be given on the tongue or by hypo- 
dermic injection, also stimulants if needed. See Apis, Alumina. Bryonia and 
Se.cale. 



220 SENSORY DISTURBANCES 



CLASS IV. -NEUROPATHIC AFFECTIONS 

In this class have been placed disorders in which functional or organic dis- 
turbances of some part of the nervous system appear as the actual or most 
probable causal factors in the development of cutaneous changes. Some diseases 
which might well be included in this class are grouped elsewhere, because of 
their likeness in some way, or association with other etiologically different 
diseases, and confusion might arise from their wide separation. Others, per- 
haps, might better find a place in some other class, but are retained here for 
similar reasons. Unquestionably the nerve structures are the medium for the 
operation of causes in the production of a large number of skin as well as other 
diseases, but many diseases have other causes which overshadow it relatively as 
a primary factor. Of such may be mentioned, as an example, the parasites of 
so-called nerve leprosy. Some affections here included may be held as not be- 
longing to dermatology at all, though possessing dermal symptoms, but their 
brief mention is justified to give a semblance of completeness to the grouping. 



SENSORY DISTURBANCES 

The senses resident in the normal skin are common sensations, which keep 
the consciousness informed of the ordinary conditions of a part, in excess, 
either pleasurable or painful, and with this is associated temperature sensation, 
though shown sometimes by disease to be distinct, as well as the most enduring 
of all senses; intimately connected with common sensation is contact sensation, 
which gives intimation of the presence of external things without specializing 
regarding their form, nature, consistence, etc., while for the latter function the 
highly endowed sense of touch (tactile and pressure sensation) is provided. 
Of these varied and composite senses of the skin it is probable that the normal 
appreciation of heat and cold is least often morbidly affected, and that the more 
ordinary contact sense is most often disordered, but it seems possible that any 
one or all may be subject to morbid disturbances. Perversions of sensation 
with no accompanying lesion of the skin are often complex, but may be observed 
in five forms, viz. : exaggerated sensation or hyperesthesia ; diminished or 
absent sensation, or anaesthesia; altered sensation, or paresthesia; pain, or 
dermatalgia; and itching or pruritus. 

Hyperesthesia. — This occurs in nervous affections, and in functional or 
organic disease connected with nerve trunks, where the integrity of the nerve 
is preserved while its excitability is increased. It may be general or local,, 
unilateral or symmetrical, the distribution giving a clue to the affected nerves. 
Every contact with the skin gives an exaggerated impression to the central 
organs. This is particularly frequent in hysteria, in which disease it is incon- 
stant in location and duration. It is frequently observed in the onset of macular 



SENSORY DISTURBANCES 221 

leprosy. A few cases are idiopathic, or at least no cause is apparent. Kalmia 
is sometimes indicated in such cases. 

Anaesthesia. — Sensation may be diminished or destroyed either by in- 
fluences upon the end organs in the skin, or the destruction of conduction in 
the nerve centre, or by central disease of the brain or spinal cord. Peripheral 
causes of anaesthesia are abnormal cold or heat, narcotic agents used locally, or 
disturbance of circulation. Diminution of sensibility by freezing is utilized 
in the method of producing local anaesthesia by the ether spray. If the heat or 
cold is carried to the extent of destroying the cutis, the loss of sensation in the 
part becomes permanent. Narcotic drugs are only effectual when applied 
directly to the exposed nerve terminals, or used subcutaneously. Injuries to 
the nerve, pressure of tumor or scar tissue, and the effects of drugs or disease 
upon the central organs produce anaesthesia in the distribution of the affected 
nerve tissue. Anaesthetic leprosy is so designated from its characteristic symp- 
toms. In these cases sometimes extensive burns of the skin may occur without 
producing pain. In hysteria, anaesthesia is as capricious a symptom as are its 
other manifestations. There may be loss of sensation to pain in some instances 
without impairment of touch, or increased sensitiveness to pain with loss of 
contact or ordinary sensation (anaesthesia dolorosa of Romberg) . Among indi- 
cated drugs see Populus cand. and Secale. 

Paraesthesia. — Symptoms of sensory irritation which do not usually 
amount to actual pain, or are unlike in kind from the usual feeling experienced 
from similar stimuli, are grouped under the term paraesthesia. They are 
usually sensations due to abnormal conditions in the nerves themselves, and 
may include one or all of the elementary forms of sensation, defined by such 
terms as formication, prickling, numbness, burning, "the velvety feeling," etc. 
True paraesthesia are indications of grave central or peripheral nervous dis- 
orders. While the abnormalities of sensation may be said to include a. multi- 
tude of sensory perversions, in many instances they merge into hyperaesthesia 
or anaesthesia, or both. For instance, in syringomyelia the application to the 
affected skin of a hot or cold substance may give rise to a painful sensation 
withoxit any appreciation of the temperature. The strictly painful paraesthesia. 
however, is known as — 

Dermatalgia or Neuralgia cutis. — This is the condition in which sensa- 
tions of pain in the skin are symptomatic of sensory irritation, not depending 
on contact and with no accompanying cutaneous lesion. The pain experienced 
varies in character, including burning, stinging and darting sensations, but 
particularly varies in degree, being often intensified upon the slightest touch 
of the clothing from the existence of hyperaesthesia. In locality it is usually 
limited to small areas of the surface, more particularly the hairy parts, the 
scalp and legs. It is most often found in the female sex. Frequently observed 
in locomotor ataxia, it is also symptomatic of general systemic disease, such as 
rheumatism and syphilis ; less general disorders such as diabetes and polyuria, 
and is also possibly symptomatic of malaria, hysteria, anaemia, etc. It some- 
times seems to be due to exposure to cold. Dermatalgia is usually to be ex- 



222 



PRURITUS 



pected to last several days or even weeks before disappearing. To diagnose it 
from ordinary neuralgia and muscular rheumatism note that the painful sensa- 
tions are very superficial in well-defined areas of the skin. Treatment con- 
sists in attention to the underlying causal condition and the use of an indi- 
cated drug. See Arnica, Bell., Kalmia, Secale and Sulphur. 



PRURITUS 

This is a form of paresthesia which is unique, in the fact that itching is 
the sole symptom of the disease, though scratching for relief may produce 
excoriations of a multiform character. Itching is a general term for a symp- 
tom occurring in some form or degree with many cutaneous eruptions, but 
pruritus stands here for a form of itching which constitutes the disease, though 
the impression on the senses may be as if something was present on the part or 
parts where the sensory disturbance appears. The sensation may be one of 
pure itching or a variation therefrom of a more or less distinct tingling, biting, 
crawling, etc. At times of slight degree or inconvenience, at others or, in other 
cases, tormenting and irritating to the nervous system to the verge of mental 
depression or disorder. Certain conditions of aggravation and amelioration 
point to the sense of contact as the chief source of error in this disease. A gen- 
tleman under my care with perineal pruritus experienced this one unbearable 
aggravation when sitting. Hence he was debarred from dining out. and as 
his tastes ran in that direction he suffered accordingly. 

Pruritus may be defined as a functional sensory neurosis of the skin char- 
acterized only by itching. To this condition Bronson has given the distinctive 
name of pruritus essentialis. This may be universal in the sense that it may 
occur alternately here and there on any part of the surface without order or 
regularity. It may be pretty constant, intermittent or remittent, is often 
aggravated by changes of temperature, and is usually worse at night. 

Pruritus senilis designates a general form of cutaneous itching supposed 
to occur with or after atrophic or senile changes in the skin, incident to old 
age, and unconnected with the common causes of itching which may prevail 
late in life as well as at'other periods. Probably in most cases of purely senile 
pruritus the atrophic changes or effects are in the peripheral nerves, but they 
may be central or intermediate. 

Pruritus hiemalis or "winter itch" is a general form which appears due to 
the cold season, occurring only in winter. It was first described by Duhring. 
who noted its most frequent occurrence upon the non-hairy surfaces, as about 
the ankles for instance ; but it also appears on other parts of the lower extremi- 
ties, arms and trunk, rarely affecting the surfaces commonly exposed to cold. 
It often begins with the cool days of fall and may be troublesome until the 
warm days of spring, or it may subside in winter. Often it is hardly noticed 
during the day, beginning in the evening or on removal of the clothing at bed- 
time. At the latter time there mav be noticed more or less associated con- 



PRURITUS 



223 



traction of the skin known as "goose flesh," which may be said to be a 
physiological effect of cold, but may be in this connection a link in the path- 
ology of this form of pruritus. With the warmth of the bed and relaxation of 
the skin, however, the itching does not always subside, but may continue to dis- 
turb the sleep for hours. Occasionally prurigo-like papules have been found 
on the parts affected, probably a result of scratching. Practically of the same 
nature is pruritus cestivitis, described particularly by English observers as 
limited to the warm seasons, and not connected with miliaria rubra. 

The local forms of pruritus show a chief preference for the genito-anal 
regions, but may occur elsewhere on the surface, following perhaps a cutaneous 
nerve, and occasionally affect the palms and soles (pruritus palmce et plantce) 
in association with hyperidrosis, gout, malaria or asthma. In a mild way it is 
not very uncommon on the face, particularly at the angle of the nose or mouth, 
and I have seen one severe case which was confined to the scalp. Itching of the 
Schneiderian membrane of the nose (pruritus narium) precedes or accompanies 
rose or hay asthma, may follow the use of opium and its alkaloids, and has 
occurred in children from irritation set up by pediculosis capitis or from in- 
testinal parasites. 

Pruritus progenitalis in many cases will have existed for some time before 
advice is sought for it, and although giving a history of primary pruritus with- 
out lesions, secondary eczematous changes may be found in either sex, but most 
frequently in men. In the cases under my observation the aggravation of the 
itching was not apparently dependent on any increase of the eruption. Hyper- 
esthesia is probably the primary local condition in the development of the 
disorder. 

Pruritus vulvae may affect all the external parts and extend into the vagina 
or beyond the genitals; more often it is confined to the labia majora, less often 
to the labia minora, introitus vaginae or clitoris. In severe cases the itching 
is intolerable and demoralizing, but fortunately in a moral sense it is largely 
a disorder of mature life, and dependent on some general or reflex condition. 
Some severe cases are due to glycosuria, uterine or ovarian diseases. 

Pruritus scroti is the form usually met with in the male, though the 
perineum and anus are only less frequently affected. From the scrotum it may 
seem to extend on to the penis more or less. I have never seen a patient, how- 
ever, who complained of the characteristic itching on the penis except in asso- 
ciation with eczema or recurrent herpes. 

Pruritus ani is a very common disorder in both sexes, and at all ages, 
either as a primary or secondary neurosis ; or in association with local anatom- 
ical changes, such as hemorrhoids and rectal irritations, eczema and fissures 
at the outlet, hyperidrosis, constipation, etc. In severe cases it is one of the 
most distressing and exasperating forms of pruritus. 

Etiology and Pathology. — Of the various sensory neuroses of the skin, 
hyperesthesia, anaesthesia, paresthesia, etc., it is chiefly the effects of the first 
and third that give rise to pruritus, and which concern the dermatologist. 
Strictly interpreted pruritus is a form of paresthesia, but is here considered 



224 PRURITUS 

as a distinct clinical entity. The causes which underlie these disturbances of 
the peripheral nerves may be congenital or acquired, local or general. The gen- 
eral nervous state known as hysteria may produce them, as well as other ex- 
altations and depressions of the nervous system. Noxious substances or an 
excess of certain elements circulating in the blood may operate on the central 
or peripheral nerves with like results, as in jaundice, gout, diabetes, nephritis 
and from certain drugs. Some of the latter, as opium, produce pruritus ap- 
parently through primary anaesthetic effects on the skin. Numerous local irri- 
tations widely situated in different cases may produce reflexly subjective 
sensations in the cutaneous nerves, such as gastro-intestinal and genito-urinary 
disorders. The casual effects of heat and cold have been mentioned. Lastly 
the neurotic impress may arise in the skin itself by muscular contractions, as 
in the familiar "goose flesh," or from senile degeneration involving as well the 
terminal nerve fibres, as in pruritus senilis. Mental impressions may produce 
temporary pruritic paraesthesia, as may be often noticed by the action of some 
among those present when a case of pediculosis is exhibited or even discussed. 
But all persistent disturbances of this kind fall within the domain of nervo- 
mental diseases, as in fact do many cases with sensory disturbances of the skin. 
Some local causes of pruritus may possibly initiate the hyperaesthesia as well 
as act as exciting factors. Thus pruritus ani and vulvae in children may be 
due to ascarides in the rectum or even in the vagina. In older people, hemor- 
rhoids, constipation, excessive local perspiration, growths which obstruct and 
produce hyperasmia of the skin may operate in the same manner. The causes 
which produce itching as a symptom of the eruptive diseases of the skin are 
not included here, though they should always be held in mind and excluded 
in searching the etiological field of pruritus essentialis, particularly the animal 
parasitic affections. Notwithstanding diligent search there will be many cases 
in which no cause is apparent, and we are forced to call them idiopathic. In 
pathology the disease is. a sensory neurosis due to irritation directly or re- 
flexly of the nerve supply of a part at some point between the central origin 
and distal terminations. 

Diagnosis. — Itching being the one diagnostic symptom it is only necessary 
to exclude other pruritic affections of the skin to establish a diagnosis. The 
absence of eruptions (except excoriations from scratching) makes this usually 
easy. Eczema may be secondary to an essential pruritus and obscure the nature 
of the primary disturbance. The history of origin will generally clear away 
this doubt. Parasites are not to be forgotten as possible factors even in unusual 
locations, and at times on the cleanly. For differentiation of pruritus from 
prurigo, see the latter. 

Prognosis depends upon the discovery and eradication of the cause. 
Pruritus hiemalis is apt to recur the next season, and the chances for a perma- 
nent cure in pruritus senilis are poor. 

Treatment. — Causal methods are first in order and importance. As these 
are sometimes seated in the nervous system, authorities on diseases of that part 
of the system may need to be consulted. General, special or local causes having 



PRURITUS 225 

been sought out, if possible, when found should be treated on lines laid down 
for those various conditions. If due to hysterical perversion, gout, constipa- 
tion, etc., physiological and pathogenetic means must first be employed to re- 
move those factors. Strictly local forms of pruritus, as about the genitals and 
anus, should receive a careful Investigation and search for local causes, which 
may demand local treatment for their correction. This applies particularly to 
pruritus ani, whether found at or about the orifice or higher up in the rectum. 
Fissures and other tissue changes at the anus may be treated locally in the 
same manner as directed for eczema involving the same parts. Any of the 
internal viscera may need attention before the pruritus can be relieved. The 
use of sedatives and narcotics is to be discouraged except in extreme cases, and 
even then the patient should be ignorant of the drug used. Local palliative 
treatment may be necessary and often mild applications, such as very hot or 
very cold water, alcohol, solution of bicarbonate or biborate of soda, or better 
than all, peroxide of hydrogen may be comforting, and being only local in their 
effect do not interfere with an indicated drug. Of the pathogenetic anti- 
pruritic agents, which should be used cautiously, carbolic acid, one to five per 
cent, in lotions, or five to twenty per cent, in oils or liniments, easily appears 
the best. These applications should not be continued nor applied to large 
areas. Orthoform, iodoform, calamin, ichthyol, resorcin and liquor carbonis 
deiergens may likewise be used. The application of the static roller electrode 
down the spine or a similar use of the high frequency currents or general gal- 
vanization will occasionally give relief in a pruritus of large extent. The editor 
recommends the direct application of a suitable electrode connected with the 
D'Arsonval-Oudin high frequency currents, to all forms of pruritus of the ano- 
genital parts. The Rontgen rays have also relieved similar conditions in these 
parts, but should be preferred for localized pruritus in other regions, because of 
the danger of producing sterility when used in the genital region. Radium 
(200,000 radio-activity), when applied to two severe cases of pruritus vulva? for 
fifteen to forty-five minutes, gave complete relief for four or five days. The 
treatment was repeated six times in one case and eight times in the other, and 
both made complete recoveries with the aid of internal medication. 

Among curative remedies sulphur most often meets the indications, but 
there are many drugs which may be adapted to individual cases. See Aeon.,, 
Agnus cast., Bovista, Calad., Cal. phos., Canab. Ind., Canth.. Colch.. Conivm, 
Cycla.. Dulc, Hydrocot., Kreos., Mangan.. Mez.. Nat. mur., N. phos., Olean.. 
Opium, Populus cand., Rumex crisp.. Salph. acid, Urtica urens, and Zinc. 



22(3 PRURIGO 



PRURIGO 



Definition. — A chronic sensory-motor neurosis of the skin, character- 
ized by excessive itching and by the immediate or secondary appearance of 
small, discrete, colorless or pale red papules, chiefly on the extensor sur- 
faces, usually beginning in early life and more or less constantly recurring 
for years, often throughout life. 

Prurigo is more common in Continental Europe (chiefly in Austria) than 
in England or America, but in its milder form it is not a very rare disease in 
this country. Its early origin, characteristic pruritic and persistently recurring 
lesions with their distribution, give to it a clinical distinctness, especially in 
comparison with pruritus, to which it is so closely related in origin. There are 
two forms which differ only in extent and degree, but never change from one 
to the^other in their course. The milder is known as prurigo mitis, and the 
severe as prurigo ferox. 

Symptoms. — Prurigo mitis. When seen in its earliest stages the erup- 
tion may consist of urticaria papules, with the usual sensations and features 
of that disorder. Within a few months hemp-seed to pin-head or larger papules 
appear, at first the same color as the skin; they can be appreciated by touch 
better than by sight. The intense itching causes some of them to be scratched, 
when they may become a pale to deep red color, or if torn, capped with dried 
blood, all of which give to them objective prominence. Later the continued 
itching and reluctant scratching leads to thickening of the skin, pigmentation 
in streaks or patches, exaggeration of the natural lines, and some mealy des- 
quamation of the surface. Commonly the eruption is limited to or most 
abundant on the anterior aspects of the legs, front and outer surfaces of the 
thigh, extensor surfaces of the arm, dorsum of the feet, on the buttocks and 
trunk, and less often on the face. The scalp may show some excoriations, and 
the hair after a time' becomes dry and frayed at the ends. The real character 
of the disease may sometimes be obscured by the secondary bloody crusts, 
pustules of various sizes, wheals, and more or less scaling of the thickened 
epidermis, or by well-marked eczematous inflammations and lesions. Careful 
search, however, will nearly always reveal some characteristic papules, perhaps 
connected with lanugo hairs which have not been torn away by scratching. In 
well-developed eases there is always enlargement of the glands in the groin, 
sometimes presenting massive tuberous swellings, while the glands of the 
axillae and above the elbow are somewhat thickened. The glandular swellings 
remain even during periods of remission of the other symptoms of the disease, 
as often occurs during the warm season. 

Prurigo ferox or agria is the name given to severe types of the disease 
which may be widely distributed, and result in pronounced eczematous, pig- 
mentary, ecthymatous and hypertrophic secondary changes, probably due to 
great neglect or extreme poverty, and hence seldom seen in this country, where 
bathing is viewed as a virtue and poverty almost a crime. The cutaneous 




Fig. 64— PRURIGO MITIS 

Patient is a girl of twelve, born in Austria; general health fair; family history neg- 
ative. Disease began about ten years ago with a gradual outbreak of small, hard, 
dry, itching pimples situated on the extremities and trunk. Pruritic sensations have al- 
ways been present, worse at night and from bathing. Symptoms abated somewhat 
after coming to this country eight years ago, but have become more intense again the 
last four years, and occasionally pustules have developed. Though evidently poorly 
nourished and round-shouldered, the patient states that she has a good appetite and 
abundance of food. The lesions consist of small excoriated papules, a few pustules 
(some ecthymatous) , all discrete and located on the extensor and outer aspects of the 
extremities and on the trunk, most numerous on the legs and least abundant on the 
body. The surfaces of the affected regions are pigmented, dry and scaly, while the face 
and flexor surfaces are paler than normal. Cured with sulphur, sixth decimal. 



PKl RIGO 



227 



changes arc most marked from above downwards, the extensor and other aspects 
of the legs presenting the worst appearance, while the flexures of the joints 
remain unaffected. The sufferers from the aggravated form of the disease are 
described as pitiable subjects, with joyless days and intolerable nights of itch- 
ing, scratching and fitful sleep. 

Etiology and Pathology. — The disease, as a rule, begins in infancy or 
early childhood, yet cases have been recorded as beginning between the fifteenth 
and thirtieth year. One of my own cases began in the fifth year of life. Boys 
are more subject to the disease than girls. Want of proper food and cleanly 
living is found in the history of most cases, but not always. The scrofulous 
taint has been occasionally observed as a probable predisposing cause. In a 
few cases no causal factors or conditions have been found to explain the origin 
of the disease, which, on the whole, is obscure. Its pathology is not much more 
satisfactory. While the distinctness of the prurigo papule is generally ad- 
mitted, whether it is primary or secondary is in dispute. The weight of evi- 
dence seems to be that it is in nature a senso-motor neurosis. The fact that 
urticarial lesions sometimes precede the real prurigo papules supports this 
view, as does the history of the earliest beginning (a period rarely seen by 
physicians), furnished by the patient or some member of the family, that the 
itching began without any eruption. The later histological investigations tend 
to show that the papules are principally connected with the ducts of the coil 
glands rather than chiefly with the follicles of the lanugo hairs, as advanced 
by Auspitz and others. White gives as his opinion that it is a condition allied 
to pruritus and urticaria, and not to be distinguished from them in its early 
stages. 

Diagnosis. — A well-developed case of prurigo is easily recognized by its 
characteristic features, especially if dating from infancy. At the very early 
stage urticarial papules may mark its nature, but a few weeks or months will 
remove all doubt. When complicated with eczema, it may be difficult to differ- 
entiate it from chronic papular eczema, which exhibits sometimes a few color- 
less papules, and may have the same sites of preference on the extensor sur- 
faces ; but there is not the same exemption of the flexures, the colorless papules 
do not predominate, and papular eczema seldom dates from infancy without 
moist lesions, crusting, etc., or long periods of intermission from the disease. 
Moreover, the glandular enlargements in the groins are seldom excessive, as 
they may be in prurigo. Ichthyosis shows a preference for the same locations, 
but is characterized by polygonal scales, not papules, is not attended with much 
itching, and if complicated with eczema, the latter is not persistent or uni- 
formly papular. Pruritus does not exhibit a persistent eruption of papules, and 
though lasting a long time, does not result in a thickening of the skin as found 
in prurigo. Then, again, there are differences in age of occurrence and loca- 
tion, as a rule. Pruritic eruptions due to animal parasites can be excluded by 
absence of the ordinary peculiarities of the latter lesions. 

Prognosis. — The hopeless prognosis made by the older Hebra is no longer 
entertained. All cases of prurigo mitis, whose hygiene and nutrition can be 



228 . PRURIGO 

improved, are probably curable, and doubtless the same is true in only a less- 
ened proportion of cases of prurigo ferox seen during childhood. It may last 
with variable intensity through life if not relieved by treatment, but frequently 
tends to disappear in advanced years. 

Treatment. — Physiological methods must be employed to improve the gen- 
eral mode of living of each patient in proportion to their needs and so far as 
practicable. If children can be taken from homes of want and filth and placed 
in a suitable hospital, their chances of immediate' gain are much increased. 
Here cleanliness, rest in bed and a nourishing diet put them soon in a way to ex- 
perience the best effects from internal medication. A daily warm bath with 
soap or bicarbonate of soda and water should be taken, to be followed by anoint- 
ing with any simple fat or oil. This softens and protects the skin and relieves 
the more intense itching. Wrapping the affected parts in rubber tissue some- 
times gives relief, and is especially adapted to the more severe cases. If pustular 
lesions or--eczema complicate prurigo, they may first need attention. Then the 
bath may need to be short and hot rather than warm, owing to the liability of 
any but hot water aggravating the eczema. Peroxide of hydrogen in full 
strength of the sixteen volume solution or diluted one-half applied to the cir- 
cumscribed patches will be found beneficial to both the eczema and prurigo, and 
its use can precede the daily anointing. In prurigo mitis further local treat- 
ment will seldom be needed, but these simple means of cleanliness and pro- 
tection must be kept up, not only during the existence of the disease, but occa- 
sionally for some time thereafter, to insure a good surface condition of the skin. 
Prurigo ferox rarely occurs in this country. It is probable that with the marked 
thickening of the skin present in that form, other local measures beside cleanli- 
ness and protection might be required to effect relief or possible cure. Patients 
who possess means to visit the natural sulphur baths may find a course thereat 
beneficial. Kaposi states that he has treated all cases of prurigo for the last 
ten years locally with naphthol in the strength of one to two per cent, in oint- 
ment for children, to five per cent, for older persons. This plan, he says, 
"possesses merely the advantages of cheapness, convenience and cleanliness, 
inasmuch as baths are unnecessary, the remedy has no disagreeable odor, does 
not soil the linen, and can be used conveniently." The Wilkinson salve, com- 
posed of tar, sulphur and green soap, has been used with success in many cases. 
Ichthyol, diachylon and carbolic acid ointments may likewise be used. 

The indicated remedy internally often has a prompt effect in relieving the 
itching, improving the skin and general health. One of my cases in which 
sulphur was plainly indicated improved at once without any auxiliary local 
measures, attention to diet or other matters of hygiene. For other remedies 
see Alumina, Ars. iod., Cal. plios.. Led.. Mangan.. Burner crisp.. Sil. and 
Zinc. 



URTICARIA 229 

URTICARIA 

I Nettle-rash ; Hives, i 

Definition. — A senso-motor neurosis of the skin, characterized by 
rapidly appearing, ephemeral, pinkish-white or reddish elevations of the 
skin, known as wheals, and attended by burning, stinging or tingling 
sensations. 

Symptoms. — The lesions of urticaria may appear suddenly without 
previous symptoms, or there may be prodromal indisposition, such as loss of 
appetite, headache, lassitude and mild fever for a few hours or a day. The 
eruption usually occurs in hard, semi-solid, roundish or oblong elevations of 
the skin, of an apple seed or larger size, averaging the size of a large bean; at 
first red; as they develop they become white in the centre, or they may stop at 
the red stage. Occasionally the wheals may be very small and it is then termed 
urticaria papulosa. This form is quite common in childhood. Rarely the other 
extreme in size is reached, and large or giant wheals are seen, egg sized or larger, 
chiefly situated on the abdomen or buttocks, urticaria gigans. Scratching the 
skin to relieve the itching may give rise to serous effusion at the apex of the 
wheals or change them into lesions of a deeper color and longer duration, and 
sometimes the excoriations are tipped with blood crusts. Even without frictions 
occasionally vesicles or bulla? constitute a feature of the efflorescence, urticaria 
vesiculosa or bullosa. Again tubercle-like swelling (in giant urticaria) may 
characterize the wheals, urticaria tuberosa. Occurring in portions of the skin 
which is quite lax, there may be considerable oedema, urticaria aedematosa; on 
the face this form may close the eyes, and in the mouth may threaten suffoca- 
tion for a short time. Another form of cedema often included as a form of 
urticaria, known as acute circumscribed oedema, or Quincke's disease, lacks the 
sensations and changes of color of true urticaria, and should therefore be ex- 
cluded. Sometimes the wheals become hemorrhagic, or develop at the sites of 
hemorrhage in the skin, urticaria hemorrhagica or purpura urticata. 

Artificial wheals can often be excited in the unaffected skin of a patient 
with urticaria by drawing the point of a pencil or the finger nail across the 
skin, the eruption corresponding to the line drawn. In this way letters and 
other characters may be made to appear. Cases showing evidences of this strong 
disposition are named urticaria factitia. Linear or welt-like lesions may. how- 
ever, spontaneously appear. The individual lesions in urticaria are usually 
very evanescent, sometimes appearing and fading away in a few minutes, rarely 
lasting more than a few hours, and the whole attack seldom exceeds one or two 
days, in which several outbreaks may occur on the same or different regions of 
the cutaneous surface. When only one crop appears, more often secondary to 
gastric symptoms and fever, it is sometimes called urticaria acuta. The chronic 
form, urticaria chronica, either from unusual persistence of the lesions (urti- 
caria perstans) or more frequently from continuous recurrence (urticaria 
recurrens) is due to some cause not discovered or not removed. Tn such ca£ 



230 URTICARIA 

the eruption recurs at regular or irregular intervals for months or years. Urti- 
caria wheals may be few or many ; they most frequently appear on the abdomen, 
chest and extremities, but they may develop upon • any part of the skin and 
occasionally upon the mucous surfaces; they may occur at any age, but are 
most commonly observed during childhood. 

Etiology and Pathology. — Urticaria may be idiopathic or symptomatic in 
origin, always admitting the existence of a certain predisposition. The causes 
of the former variety probably act directly or reflexly on the peripheral vaso- 
motor system of nerves, and embrace a long list of external irritants, among 
which are the bites of insects, contact with certain kinds of shell-fish, with cer- 
tain kinds of plants, particularly the urtica wens, from which the disease 
derives its name. It may be occasioned by exposure to cold air, or other climatic 
influences; by the contact of too heavy or too closely worn clothing; by mechan- 
ical or medicamentous applications, or by mechanical or surgical traumatisms. 
In many-instances the urticarial eruption is not limited to the site of the 
irritation or injury, but invades a much larger area. 

Symptomatic urticaria is due to equally differing internal conditions, 
though it is estimated that ninety per cent, arise from disturbances in the 
alimentary canal, due to over-indulgence in, or idiosyncrasy regarding such 
articles of diet as oysters, lobsters, eggs, pork, sausage, cheese, strawberries, 
dates, raisins, figs, raspberries, gooseberries, mushrooms, salads, spinach, pears, 
oatmeal,, beans, onions, almonds, and other nuts ; canned fruits, vegetables and 
potted meats ; honey, confectionery, tea, coffee, cocoa, beer, champagne, or other 
alcoholic beverages. A similar idiosyncrasy to large or small doses of certain 
drugs leads to attacks of urticaria. Such effects are witnessed sometimes from 
quinine, antipyrine, turpentine, chloral, cubebs, copaiva, valerian, arsenic, 
cinchonidia, hyoscyamus, the salicylates, santonine, and the iodide of potas- 
sium. In children, intestinal worms are occasionally the source of an attack. 
Geni to-urinary disorders in both sexes may at times provoke an outbreak of 
urticaria. Other diseases which may be preceded, attended, or be followed by 
wheals are asthma, malaria (sometimes intermittent in type), rheumatism, 
purpura, pemphigus, prurigo, and the eruptive fevers. Lithaarnia, disorders 
of the kidneys, pregnancy, dentition, mental emotions, such as anger and fear, 
are some of the other causes which excite its production. "When the susceptibil- 
ity is pronounced the effect is frequently marked from a seemingly insignificant 
cause. Thus one strawberry, a bit of fish, or a grain of cinchonidia may be 
sufficient, when swallowed, to induce an extensive attack of urticaria, which 
may recur with each indulgence. Pathologically the wheals of urticaria are 
produced by a sudden oedema and exudation in a limited area of the upper 
layers of the skin, probably due to spasmodic contraction of the capillaries 
from vaso-motor influence. The resistance of the tissues of the skin to the 
semi-solid swelling being the greatest at the centre, an anaemic point or white 
spot appears in contrast with the congested and reddish border. The more 
acute the eruption in its development, the more marked is the characteristic 
pink and white color of the wheals. With the return of vaso-motor equilibrium 



URTICARIA 28 1 

rapid absorption follows. When the wheal occurs at or about the site of other 
lesions the pathological changes of urticaria are added to those already existing. 
Unna holds that the wheal is due to a spastic contraction of the superficial 
veins. 

Diagnosis. — Discriminating urticaria from other eruptions is not difficult; 
frequently the patient or friends have anticipated the physician in that direc- 
tion. Occasionally the practitioner is called upon to diagnose an eruption 
which appears and disappears at night, which he had not been called to sec at 
the time. On inspection in such cases some delicate mottlings of the surface 
where the wheals have been may often be found, and he may be able to excite an 
artificial wheal by scratching the skin with the finger nail. In any event the 
ephemeral character of the eruption in association with the sensations of sting- 
ing, itching or burning leave no doubt as to their nature. When the eruption 
is of longer duration there may be a resemblance to erythema. In erythema 
simplex the patches are larger, have not developed from wheals, and are not 
elevated above the surface. In multiple erythema the lesions are much more 
persistent, and are unattended with the marked subjective sensations of urti- 
caria. Moreover the former is symmetrical, and in the nodose form tender on 
pressure. Urticaria bullosa might be mistaken for pemphigus, but the presence 
of one or more urticarial wheals and its brief duration serve to distinguish it. 
Urticaria of the face is differentiated from erysipelas of the face by the more 
diffuse swelling and redness in the latter disease, its longer duration and ac- 
companying constitutional symptoms. An immediate eruption from the sting 
of an insect can usually be distinguished by the minute puncture in the centre 
of the lesion. It is to be borne in mind, however, that a more or less general 
urticaria may sometimes follow from a single insect wound. 

Prognosis. — This is favorable for most cases who will carry out preventive 
and curative methods of treatment. 

Treatment.— Causal measures of treatment are of first importance. In 
idiopathic urticaria the removal of the cause and perhaps a single dose of an 
indicated remedy are alone sufficient to effect a rapid cure. The cause therefore 
should be sought for, if not apparent, among the classes which have been enu- 
merated, and removed. In symptomatic urticaria also removal of the cause is 
the first step. Here, however, it may not be immediately possible to banish the 
etiological factor. If that be a general or localized disease, continuous or re- 
peated treatment may be required to effect a complete cure. Such is frequently 
the case in chronic or recurring urticaria. Disorders of the kidneys, uterus, of 
the nervous system, respiratory tract, the alimentary canal, limited conditions 
due to pregnancy, dentition, or the menopause ; general states like malaria, gout 
or rheumatism may furnish the indications for treatment. The possible etio- 
logical relation of drugs employed internally and locally are to be borne in 
mind. If acute urticaria is due to irritating contents of the stomach, soon after 
eating, an emetic, such as twenty drops of ipecac, may be given to unload the 
mechanically offended stomach. If some time after eating, and the irritation 
is in the intestines, an effective cathartic suited to age and patient (Yastor oil or 



232 URTICARIA PIGMENTOSA 

a saline water) may be employed to remove the causal factor. If due to any 
one or more articles of food, however small in quantity, correction of the diet 
is of importance. The indicated internal remedy should be given in all cases. 
It not only hastens the immediate subsidence of the attack, but it tends to 
prevent recurrence, and as a means of relief from the painful sensations it is 
usually far more effective than any local treatment. Hence, local measures 
aside from the employment of means to remove a cause are uncalled for in 
urticaria, unless we except the alkaline baths containing sodium bicarbonate, 
sodium biborate, potassium bicarbonate or sodium hyposulphite. Starch, gela- 
tin or bran may be added to these baths or used alone. Experience alone can 
say which of these substances will prove the most satisfactory in any single 
case. The following drugs have been found effective in about the order named : 
Apis, Arsenicum, Rhus tox., Antipyrine, Ledum, Nat. mur., Gopaiva, and 
Urtica wens. See also. Aeon., Ant. crud., Bovista, Bry., Calad., Cal. caro., 
Chinin. sulph., Chloral, Coca, Coc. ind., Colch., Coni., Dulc, Hepar, Hyper., 
Ereos., Lack., Nat. phos., Opium, Rumex, Sul., and Terebinth. 



URTICARIA PIGMENTOSA 

(Xanthelasmoidea.) 

This disease differs so much from ordinary urticaria as to necessitate sepa- 
rate discussion. It is a rare affection, but likely to be seen in any large clinical 
experience. Beginning in childhood, usually within the first few months, it 
may have the same appearance at first as common urticaria ; but instead of the 
individual wheals soon disappearing, they tend to persist on one or more 
regions, sometimes in small groups. If some lesions partially subside, a fresh 
exudation may re-form on the same sites, each time adding to the hyperplasia. 
Instead of the pink and white color of ordinary wheals, or if pinkish at first, 
they soon take on a yellowish hue which deepens in time to a yellowish-brown. 
At' this stage the lesions appear like firm pea- to bean-sized papules, which may 
remain unchanged for a long time, and if new lesions continue to form, the 
variations in color from the reddish tint of the more recent to the brownish hue 
of the older lesions may be seen in some cases. Occasionally the papules 
coalesce to form moderate sized patches which at a certain stage may resemble 
xanthoma. During the development of the disease, if the lesions are irritated, 
they swell up and take on the appearance of wheals again. Itching may precede 
or attend the formation of the wheals : when it is severe some temporary wheals 
are apt to appear and factitious urticaria is not unusual. Bulla; sometimes 
form on the older nodules, and ecthymatous lesions may result from scratching. 
These secondary eruptions are not liable to arise in the non-pruritic cases. 
After a variable time, usually some years, fresh lesions cease to occur, the older 
ones begin to absorb, and generally before puberty the swelling and pigmenta- 
tion have disappeared. Exceptionally the elevations are temporary, and pig- 
mentation is only persistent. One case has been reported followed by atrophic 
scarring, and a few with atrophy of pigment. 



ANGIONEUROTIC OEDEMA 

Etiology and Pathology. — Nearly all cases begin in infancy showing a 
certain hereditary tendency or congenital predisposition. Of the eighty-three 
cases reported by Blumer, in seventy-one per cent, the condition began within 
the first year. It may appear later and Elliot has reported a case which began 
at twenty-seven, had existed five years at the date of report, and the patient was 
subject to factitious urticaria. The pathology differs from ordinary urticaria 
in that the papillary layer of the corium is filled with mast cells arranged in 
columns, which formation is characteristic of the process. In some instances 
these mast cells may extend through the cutis and into the subcutaneous tissue. 
There is a large deposit of pigment in the basal layer of the rete. 

Diagnosis. — This is easily made on the following points: Origin in in- 
fancy, persistent eruption and duration of wheals or large papules, with pig- 
mentation for many years, or until about puberty. With extreme rarity 
urticaria with pigmentary staining may originate in adult life. 

Prognosis and Treatment. — The disease spontaneously disappears at or 
before puberty. This tendency to resolution can probably be hastened by in- 
ternal treatment. The remarks on physiological methods in the treatment 
of common urticaria may apply here if needed. One of my cases improved 
under berberis lx. Among other probably curative internal remedies see 
Antipyrine, Arsenicum, Lach., Nat. mur. and Phosphorus. 



ANGIONEUROTIC CEDEMA 

{Acute circumscribed oedema; Acute idiopathic oedema; Acute non-inflam- 
matory oedema; Giant swelling; Quincke's oedema.) 

Many cases of suddenly occurring, circumscribed swelling of the skin have 
been noted by different observers. Sometimes they have been found associated 
with manifestations of urticaria, rheumatism, purpura, erythema nodosa, etc. 
In most cases the affection appears unconnected with other diseases, but is fre- 
quently preceded by slight malaise, and sometimes concomitant gastro-intestinal 
symptoms indicate implication of that tract by the disease or other dis- 
turbance. It may also attack the mucous membranes of the mouth or throat, 
sometimes producing alarming suffocative distress. Commonly the ail'ection 
occurs in isolated, circumscribed swellings, varying in size from a half dollar 
to an orange, or larger, in circumference. The surface of the skin over the 
enlargement may be unchanged in color, or tinged more or less with red ; more 
often it presents a smooth, shining appearance. The swelling does not give 
rise to much pain or itching as a rule, but may have a feeling of tension, more 
or less, at the height of development. Usually individual lesions last only a 
few hours, or at most one or two days, but fresh swellings may develop as 
others disappear and prolong an attack for some time. Although any part of 
the body may be the seat of the process, it is commonly located on the face and 
genitals. All of my own cases have been upon the face; two were confined to 
the upper lip, which in one case was swollen to the size of a large hen's 



234 PURPURA 

rapidly subsiding at the end of five or six hours. In a third case, the oedema 
involved the right cheek, and was of longer duration. Attacks may recur on 
the same or other regions without limit, but the general health in the intervals 
is generally unaffected, and the resolved lesions leave no trace behind. 

Etiology and Pathology. — The disease may occur at any age, but is 
most common in adult life and in men. It seems probable that a predisposition 
of the nervous system to this affection may be sometimes hereditary. Milroy 
has noted its occurrence in six generations in one family, and Osier in five 
successive generations. The exciting causes may be of the same nature as 
those which provoke attacks of urticaria or erythema multiforme, to which it 
seems closely related. The pathology is not clear, though there is little doubt 
that the acute temporary derangement in the peripheral circulation resulting 
in sudden serous effusion is brought about through the vaso-motor nervous 
system. 

Diagnosis. — This form of neurotic oedema is to be distinguished from all 
forms of secondary oedematous swelling of the skin, hysterical (menstrual) 
oedema and giant urticaria. The latter may be known by the sensations which 
are felt in the lesions, and their pink and white color; still, in some cases the 
similarity is very close and fortunately a positive differentiation is not im- 
portant. Hysterical oedema is usually more persistent, as are secondary forms 
of dropsical swelling; besides evidences of primary disease are usually obtain- 
able in the latter cases. 

Prognosis. — Probabilities of cure are good. It may not be possible to 
entirely overcome the tendency to recur in every case, and the possibility of 
fatal suffocation when the larynx is attacked or the glottis involved is to be 
kept in mind in forming an opinion. 

Treatment. — Causal methods of treatment as laid down for urticaria, and 
the indicated remedies, are the only measures needed in the great majority of 
cases. The latter after careful selection should be given occasionally for some 
time after an attack has subsided. The similimum may be found among such 
drugs as Agar., Antipy., Apis, Helleb. nig., and Urtica urens. When the loca- 
tion of the acute swelling threatens life, hypodermic injections of muriate of 
pilocarpine in the strength of one-twentieth to one-fourth of a grain may 
hasten immediate relief by its well known action of exciting free perspiration. 
Salt and water, applied over the region of the spine, as recommended by Hyde, 
has yielded satisfactory results. 



PURPURA 

Definition. — An extravasation of blood into the skin not due to trau- 
matism. 

Purpura, while now regarded as a symptom rather than a distinct disease, 
is so often the predominant feature that like pruritis essentialis it claims a 
separate consideration. Hemorrhages in the skin may take the form of (1) 




Fig. 65.— PURPURA SIMPLEX 

Patient is a man of twenty-three, single, tall and slender, without a history of 
any antecedent disease or a family history of hemorrhagic disorders. Disease began 
without any premonitory symptoms, the spots on the legs being first noticed while 
dressing in the morning. These multiplied during the day, when he felt a sense of 
heaviness in the legs and body while about his work. At the clinic next day patient 
stated that he felt dull, heavy and languid, as though over-tired, but otherwise in 
no sense ill. The lesions consist of numerous da ret -colored macules, confined to 
the legs and thighs, and varying in size from a pin-head to a thumb-nail; the larger 
spots are irregular in outline and situated on the ankles up to the calf of the leg. 
The distribution of the eruption is symmetrical; it is scarcely appreciable to touch 
and the color of the earlier lesions is not diminished by pressure. Cured with ph,,*- 
■phorus, sixth decimal. 




Fig. 66.— PURPURA SIMPLEX 



Patient, a woman of sixty-five. Disease began while she was confined to her 
bed with malarial fever. Lesions consisted of many small bright red macules which 
appeared in crops for a week, never extending above the waist line. Marked bruised, 
sore and lame sensations were felt, and led to the use of arnica, third decimal, which 
cured the condition in two weeks. 



PURPURA 285 

petechia, red or livid spots under the epidermis from tin: size of a pin point to 
that of a finger nail, not elevated above the surface nor disappearing on 
pressure; (2) vib ices, of similar character occurring in streaks; (3) ecchyn 
of largeT size, airy shape and often attended with some swelling ; and rarely ( t ) 
papules (lichen lividus) when the effusion is at the mouth of a hair follicle. 
There may occur blood tumors (hematomata) and sometimes super-epidermic 
effusions or hemorrhagic bullae. Hematidrosis or blood sweat has been in- 
cluded with the disorders of the sweat glands. When hemorrhage occurs in 
association with the lesions of other diseases, mention of it may be found in 
the descriptions of the latter, and when secondary to manifest special or general 
disease they take their true place as symptoms of minor importance, especially 
to the dermatologist. 

Some of the characteristics of purpura lesions (of which the petechial are 
the most common) are their sudden appearance, unchanging size, except by 
fresh hemorrhage; their color not disappearing on pressure but by a progressive 
evolution from the early reddish or purple to the bluish, yellowish-green, and 
brownish tints common to the ordinary bruise. 

Purpura simplex represents the most usual clinical type of cutaneous 
hemorrhage. Petechial lesions of various sizes, usually round or oval, appear 
without warning, often without the consciousness of the patient, who may 
accidentally discover them on dressing or undressing. Sometimes attacks are 
preceded by moderate constitutional symptoms of malaise, loss of appetite, etc., 
and occasionally slight itching attends the onset of the disorder; more often 
it is absent unless some other eruption, as wheals or blebs, coexist with the 
purpura. Generally the spots are located upon the legs, but they may appear 
upon any part of the skin or on the visible mucous surfaces. The individual 
lesions may be isolated, or some may be joined together to form irregular 
patches. Fresh lesions continue to appear in crops for a shorter or longer time, 
so that an attack may last from two weeks to a month, rarely longer. During 
this time all the spots of each crop pass through the gradations of color before 
mentioned. 

Purpura hemorrhagica (morbus maculosus Werlhofn) may also appear 
without antecedent symptoms or it may follow the simple form, from which it 
differs chiefly in degree. More often it is preceded by aching in the legs, gen- 
eral lassitude, and sometimes by extreme debility, headache and complete 
anorexia. Commonly the lesions appear first upon the lower extremities and 
contiguous parts of the trunk, and may by frequent crops rapidly extend all 
over the surface of the body. At the same time or later, hemorrhages may 
occur from any of the mucous tracts, and blood appear in the urine, be ex- 
pelled from the bowels, stomach, bronchia, throat or nose. Hemorrhages may 
also take place into the inner structures or cavities of organs, producing symp- 
toms and danger according to their location. On the skin there may be all 
forms of lesions due to hemorrhage, varying in shape, size and color: the latter 
depending somewhat on the relative duration of the spots. The duration of an 
attack, if not interrupted by death from more or less rapid exhaustion, seldom 



236 PURPURA 

exceeds two or three weeks, and the bleeding may cease gradually or suddenly. 
The general health is little affected in the less severe cases, and when uncom- 
plicated by hemorrhages into vital organs the resulting anaemia soon disappears. 
Thus the majority of cases terminate in recovery. Occasionally febrile symp- 
toms have been observed to precede, attend or follow purpura (purpura febrilis), 
but the real nature of these rare cases is in doubt. 

Hemophilia (bleeder's disease) is probably related to purpura hemor- 
rhagica. It is characterized by free and persistent bleeding from slight trau- 
matisms, and is frequently hereditary. Purpura papulosa is occasionally seen 
in the form of small, projecting lesions at the hair follicles, usually on the legs 
or other dependent parts of the aged, scrofulous or cachectic individual. 
Hematomata or blood tumors, may be superficial or deep seated, and vary in 
size, consistency and shape. They may arise from the rupture of a single 
blood-vessel, or from some usual conditions favoring extravasation of the 
blood. All save one of my own cases have been in infants or young children ; 
most of them were suffering at the time from infantile scurvy (Barlow's dis- 
ease), and in one case an ecclrymoma was found, the surface size of a hen's 
egg, hard and tender on touch. In the scorbutic such swellings may be sub- 
periosteal and painful. Purpura scorbutica or scurvy occurs principally 
among those who are compelled to subsist on a limited or improper diet for some 
length of time, and are unable to exercise properly. It is common among 
sailors, prisoners and arctic explorers. Languor and depression, swelling of one 
or several joints, a febrile show, hemorrhages, petechias, ecchymoses and painful 
ecchymomata may all occur. The condition is curable, though tedious in its 
convalescence. 

Purpura rheumatica, owing to its peculiar symptoms, is frequently de- 
scribed as a separate inflammatory disease under the name of peliosis rhevr 
matica, but, as its lesions are essentially hemorrhagic and its etiology probably 
similar to some other forms of purpura, it seems proper to associate it with 
the latter. Premonitory symptoms of malaise, insomnia, anorexia, with or 
without slight fever, may be felt; these together with pains in the limbs, espe- 
cially in the joints of the knees and feet, which are frequently swollen and 
tender, may continue from one to three days. Then an eruption of slightly 
raised papules or patches appears, usually most abundant at and about the 
painful joints, but it is not always limited to these regions, the favorite sites 
being the knees, calves, ankles, wrists, elbows, and least of all the trunk. 
With the development of the eruption the pains generally subside. Exception- 
ally the pains may follow instead of precede the eruption. The lesions vary 
in size from a minute point to a bean, or larger; of a bright red color at first, 
they soon become purplish, finally disappear by absorption, as in other purpuras, 
in ten to fifteen days. Sometimes the lesions are of the same kind as usually 
seen in purpura simplex, and. rarely, as in purpura hemorrhagica. Eecurrence 
of the attack is apt to follow, and sometimes successive relapses prolong the 
disease for months. "While the systemic temperature sometimes runs up to 
102° it is not constant, and febrile disturbance may be absent altogether in the 



PURPURA 287 

most severe eases. Neither does the change of temperature appear to be con- 
nected with any one or other development in the eourse of the disorder. 
Hemorrhages from the kidneys during an attack of peliosis rheumatica have 
been observed by Kaposi, who also mentions a fatal case due to hemorrhage into 
the mucous membrane oil the larynx. Henoch and others have observed hem- 
orrhages from the gastro-intestinal tract during the course of the disease. 
Though these complications must be rare they nevertheless help to establi.^li 
the relation of the disease to purpura. On the other side, the occasional origin 
of endocardeal and valvular lesions of the heart, in the course of peliosis, to- 
gether with the joint affections, link it more or less closely with rheumatism. 
The editor has seen two cases who died of endocarditis. In conclusion, it might 
be said that although there are three sets of symptoms, the cutaneous, the 
arthritic and the gastro-intestinal, present in most cases, usually only one 
group is pre-eminently prominent. 

Purpura medicamentosa, or hemorrhages of the skin, as an effect of a 
drug, is usually due to some idiosyncrasy. Among such drugs and poisons may 
be mentioned arsenic, arnica, alcohol, belladonna, chloral, chloroform, ergot, 
iodine, phosphorus, and the snake poisons. 

Etiology and Pathology. — The spontaneous or true purpuras, while 
doubtless, in a certain sense, secondary, are apparently due to many indefinite 
and varied factors. The predisposition to purpura may be hereditary, as in 
cases of hemophilia. It may be acquired through influences which change the 
quality of the blood, interfere with the integrity of the blood-vessels or produce 
temporary derangement of the vaso-motor nerves. 

Blood changes may result from anaemia of a general character, from the lack 
of some necessary element, as in scurvy; from the development of "some poison 
— an alkaloid, possibly the result of faulty chylopoetic metabolism" (Osier) ; 
from an excess of some normal product, retention of waste material, or from 
the introduction of some foreign substance into the blood, as in cases of pur- 
pura rheumatica ; purpura from drugs and poisons, and often probably from 
the presence of bacteria and their products (Letzerieh). Weakness of the 
walls of the Mood-vessels may be from a defect of nutrition, as in purpura 
neonatorum; from changed nutrition, as in purpura senilis; from degenerations 
following very acute or long illnesses, constitutional diseases like syphilis, 
tuberculosis, etc. In the existence of even moderate vascular weakness exciting 
•causes like muscular effort in mechanical pursuits, parturition, coughing, con- 
vulsive seizures, loss of support from atmospheric pressure, as at high altitn- 
■etc., may precipitate hemorrhagic extravasations. 

Disturbances in or through the nervous system, which presides over peri- 
pheral circulation, are probably factors in the causation of the major part of 
idiopathic purpuras. These are in nature vaso-motor effects of an advanced 
kind, which so relax the vascular walls as to permit, with increased pressure, 
filtration of blood into the tissues, or sometimes only transudation of blood 
coloring matter, and in many, if not most, cases actual rupture of the vessel. 
Thus temporary mental emotions of grief, shock, excitement, etc., may oees- 



238 PURPURA 

sionally result in purpura. Other functional neuroses as hysteria and neuralgia 
may cause hemorrhages into the skin. Purpuric lesions, sometimes produced 
by inhalations of chloroform and from snake poisons (Weir Mitchell), are 
likely of the same nature. Organic disorders of the sympathetic nerves have 
been shown experimentally and clinically to produce purpura, and Schwimmer 
is of the opinion that purpura is essentially a tropho-neurosis. Chronic af- 
fections of the spinal cord as well as of the spinal ganglia have been attended 
or followed by purpuric lesions in the skin. Acute purpura {purpura fulminans 
of Henoch), which may be fatal in a few hours or days, can only be explained 
through some profound effect on the vaso-motor nerves, whether primarily 
originating from microbic invasion, toxaemia, or some unknown source. Not- 
withstanding the numerous causes which may predispose to, or operate to pro- 
duce purpura, there are many cases in which the etiology is obscure. The 
pathological cause, escape of blood or blood coloring matter from the blood- 
vessels into the skin (chiefly the corium), into the mucous surfaces, and some- 
times into the parenchyma of organs, is not uncertain ; though whether the 
method of escape is by rupture of a small vessel, by filtration of blood through 
the walls of the vessel, or by transudation of blood coloring matter only in a 
given case, may be somewhat in doubt. Inflammatory processes may be present, 
and micro-organisms have often been found, but they are not typical of pur- 
pura. 

Diagnosis. — Purpuric lesions are easily recognized by their sudden appear- 
ance, often in successive crops; purplish color, not disappearing on pressure, 
but finally fading away after passing through gradations of color like an 
ecchymosis from a bruise. Contusions may be distinguished by their location 
on exposed parts, not occurring in crops, and often by a history of an accident. 
Purpura hemorrhagica may be differentiated from purpura simplex by the 
occurrence of hemorrhage from the mucous surfaces, rarely from the skin 
itself, and usually by more marked prodromal or attendant depression and 
fever. Purpuric lesions associated with other eruptions of the skin, such as 
urticaria, erythema nodosum, pemphigus, or occurring in the course of sys- 
temic diseases, such as the infectious fevers, septicaemia, etc., may always be 
recognized by the history and diagnostic symptoms of the primary or real dis- 
ease. Two allied affections, peliosis rheumatica and scurvy, ought not to pre- 
sent much difficulty. In peliosis the joint pains and some swelling, which 
commonly precede the eruption for two or three days, and the raised or 
papular character of the purpuric lesions make clear the identity of this 
form of disease. Scurvy will nearly always show swelling of the gums and 
other signs of the scorbutic state. Its purpuric lesions are larger, and mus- 
cular pains and soreness are often pronounced, especially in the infantile 
form. Moreover its dietetic origin can always be ascertained. Some insect 
bites may become petechial in character, but they can be distinguished from 
purpura by the early hyperaemic border, central point of puncture and by 
a discovery of the cause. The possible influence of drugs may be eliminated by 
inquiry as to their use. 






ROSACEA 28B 

Prognosis. — Tins is good for cases of purpura simplex, bul it is not po 
ble to determine at an early stage that a mild attack will ool become hemor- 
rhagic. Even in most cases of the latter recovery ensues. The dangers from 

excessive loss of blood or from hemorrhage into the brain or other vital organs 
is to be kept in mind. Purpura in pregnancy, the new born and the feeble, is of 
graver significance. Predictions as to duration can only be made in a general 
way. Relapses are not uncommon. 

Treatment. — Causal methods should be instituted when the underlying 
factors can be learned and remedied. This may be in the direction of improved 
nutrition by diet, fresh air, sunlight and other physiological means. In scor- 
butic states correction of diet is the chief treatment. Eest in the recumbent 
position should be insisted upon except in the most trivial cases, and in severe 
forms rest in bed should be continued for a time after hemorrhages have ceased. 
Local applications of ice and the use of hemostatics is advisable when a hemor- 
rhage is present. The skin can be supported if necessary by bandaging the more 
dependent parts where gravity helps to weaken the blood-vessels. The indicated 
drug remedy is very important, and is easily selected, as a rule. See Arn.. . 1 rs., 
Berb., Bry., Carbo veg., China, CJilor., Coca, Copaiva, Crotal., Kali iod., Lack., 
Nat. mur,, Phos., Rhus tox., Secale, Sal ph. acid, Terebinth., and Vipera. 



ROSACEA 

(Acne rosacea; Acne erythematosa; Gutta rosacea, etc.) 

Definition. — Rosacea is a chronic congestion of the skin of the face, 
leading to permanent redness, capillary dilatation, secondary acne, and 
sometimes to hypertrophic thickening of a portion of the affected parts. 

Symptoms. — Rosacea is a disease of adult life, and begins as a temporary 
congestion or redness of the "flush area" of the face, which recurs at varying 
intervals. After a time the intervals become shorter or only remissions of the 
redness occur until the middle third of the face or beyond is the seat of 
hyperemia, varying in color from a bright red to a purplish hue. There may be 
sensations of heat in the affected skin at times, and occasionally it is noticeable 
to touch, but more often the surface is cool. The congestion instead of remain- 
ing active as at first becomes passive, and when the color is made to disappear 
by pressure it slowly returns. Frequently the surface of the skin becomes shiny 
and tense, especially the nose, which is often the centre of the most marked 
congestion. Seborrhoeal disturbances may make the skin oily or cover it in 
spots with fatty scales, which sometimes plug the dilated orifices of the oil 
glands, and in some cases a condition of seborrhceic dermatitis is engrafted on 
or becomes a part of the rosacea. In this stage also folliculitis or perifolliculitis 
is apt to ensue and isolated acne lesions appear, in no way differing from those 
of acne simplex except in the absence of comedones. Larger lesions, as in acne 
indurata, may mingle with the smaller papules and pustules, though they may 
be absent altogether or only appear in a later stage ; and occasionally rosacea 



240 ROSACEA 

pursues its course uncomplicated with acne. The disease may exist a long 
time, for months or years, without further development, perhaps remitting or 
nearly subsiding under changed conditions of living or of climate, but sooner 
or later, unless relieved, it passes into the second stage. 

In the second stage dilated blood-vessels become visible on the surface, either 
as fine lines, often numerous and widely distributed, or as larger anastomosing 
vessels, sometimes tortuous and slightly varicose. These are usually most 
marked upon the nose, but may form in a less degree upon the cheeks, often giv- 
ing to the skin a bluish or violaceous tint. During this stage the seborrhceal and 
acnoid feature may be more marked, or occasionally the surface may be dry, 
uneven and somewhat scaly. Untreated this type of the disease may continue 
indefinitely, and the third or hypertrophic stage, except in a very moderate 
degree, may be seldom seen. 

When the third stage does develop it consists of a connective tissue growth 
about the vessels that goes on to form tubercle-like, non-inflammatory enlarge- 
ments at the end and sides of the nose, expanding it longitudinally and later- 
ally, rosacea hypertrophica. In extreme cases the process may continue until 
the nose is enormously enlarged (rhino pliyma) , overhangs the mouth and chin, 
and is more or less covered with deep red nodules, with here and there dilated 
or varicose blood-vessels. Most cases of hypertrophic rosacea occur in alcoholics 
whose occupations expose them frequently to the extremes of weather. 

Etiology and Pathology. — Eosacea begins most often between the thir- 
tieth and fortieth years of life, but it originates not infrequently before and 
after that period. One of my own cases began in the eighteenth year, and 
Bulkley mentions a case at eighty-four. Women up to the age of forty are 
more subject to the disease than men, as four or five to one. A weak circulation 
which determines a sluggish blood current in the vessels of the skin, lithsemia, 
the gouty habit, sedentary living, predispose in a measure to rosacea. The more 
direct factors are reflex from irritations in the alimentary organs or tracts, 
such as the various forms of dyspepsia, constipation, etc. Catarrhs and other 
affections of the upper respiratory tract are not uncommon causes in the 
author's experience. Functional or organic affections of the uterus and its 
appendages may operate reflexly on the circulation of blood in the face. Once 
I have seen rosacea develop coincidently with the growth of uterine fibroids and 
subside with the reduction in size of the latter. Genito-urinarv affections in 
men may occasionally act as causes. In both sexes a rich or highly seasoned 
diet, fermented liquors, hot tea and coffee, when habitually taken in excess, are 
common causes. It is not an unusual thing to hear patients say such and such 
liquids "go right to my face." Local affections like acne and seborrhoea may 
cause increased determination of blood to the face, and injudicious use of local 
applications, such as cosmetics, or even hot water, so common in recent years 
for all sorts of purposes, may be contributing factors. Several cases in which 
persistent aggravation has followed repeated applications of hot water have 
come under the writer's observation; while the temporary aggravations which 
may follow from exposure to artificial dry heat, to the sun. as well as to the 



ROSACEA 2 1 1 

extremes of cold and winds, arc well known. The pathology of rosacea, as has 
been indicated, is primarily a vasomotor disturbance, which by frequent re- 
currence impairs the tone of the peripheral blood-vessels of the face, Leading to 
secondary dilatation of the vessels, inflammation, glandular enlargement, and 
finally in some cases to trophic changes, largely in the direction of connective 
tissue growth. 

Diagnosis. — The characteristic method of development of rosacea begin- 
ning with intermittent redness, later becoming more constant, followed often 
by capillary dilatation and its symmetrical location on the middle third of the 
face and adjacent parts of the cheeks, makes it quite distinct from other dia 
of this region. It might resemble seborrhceic dermatitis, lupus erythematosus, 
acne, and in extreme development the nodular syphilide. 

Seborrheic dermatitis would not begin with temporary flushing of the face, 
or later exhibit dilated blood-vessels. It would show more abundant fatty crusts 
and frequently a lack of symmetry. It should be borne in mind, however, that 
seborrhcea sometimes complicates rosacea. 

Lupus erythematosus commonly extends by peripheral growth, in more 
sharply defined patches, somewhat raised borders, and over the affected surface 
there are more or less dry and adherent scales, which often plug the orifices of 
the sebaceous ducts. Atrophic scarring may be found as a result of the disease, 
all unlike rosacea. 

Acne vulgaris primarily begins as papules mingled with comedones, without 
marked redness, and may occur upon the upper part of the trunk as well as on 
the whole face, whereas rosacea begins with redness, chiefly of the middle por- 
tion of the face, and papules if present are of secondary development. 

The superficial gummatous syphilide of the tertiary period, occurring on the 
nose, might look like advanced rosacea on casual examination, but the history 
of development, often lack of symmetry, the presence of ulceration under the 
crusts or other evidences of syphilitic lesions, past or present, would serve to 
clear away all doubts. If positive signs of rosacea are present in such cases, the 
two affections may be found to coexist, or some other eruptive lesions, as from 
drugs, may help to simulate a syphilide. 

Prognosis. — Most cases of rosacea of the first and second degrees, and some 
in the third stage, can be relieved or cured by appropriate treatment. 

Treatment. — This must be directed to existing causal states wherever 
found. Often physiological methods will be found adapted to their relief, in 
regulation of the diet, to relieve dyspepsia, constipation, and improve nutrition. 
Every article of food and drink which soon after being taken produces a de- 
termination of blood to the face should be rigidly excluded from the diet. All 
aggravating influences, as exposures to extremes of temperature, etc., should be 
avoided so-far as possible. Rosacea is much the most common in women, hence 
menstrual disturbances, and disorders of the uterus, ovaries, vagina, may de- 
mand relief before a resulting rosacea can be cured. Diseases of the nose and 
throat may perpetuate rosacea if unrelieved. General states like anemia, 
lithaemia and gout may require attention. The details of treatment of these 



242 HERPES 

and other related affections need not be specified here. Very often they will 
afford indications for internal pathogenetic remedies as well as other lines of 
therapeutics. If judicious physiological (causal)- and internal drug treatment 
can be carried out, the need of local treatment is minimized. However, this 
ideal method is often impossible, and the stimulating lotions recommended for 
acne vulgaris may be necessary. The high frequency currents should be used 
once or twice a week, for such cases of the first stage and sometimes in the 
second stage. This latter phase of the disease usually responds to radiotherapy 
more quickly and satisfactorily (see technique under acne vulgaris). The 
telangiectases are not often influenced by the Ebntgen rays, but may respond to 
phototherapy (see remarks in Part I. on phototherapy) and for rosacea of 
small areas it has been reported as more effective than radiotherapy. In the 
second stage, massage of the face by a skilled operator may be of decided bene- 
fit in restoring tone to the weakened vessels and other structures of the skin. It 
may be-employed for from twenty minutes to an hour every two or three days. 
Large or varicose vessels may need to be punctured, scarified, or destroyed by 
electrolysis to insure their disappearance. For electrolysis the same appliances 
can be used as in the removal of hairs, the needle being inserted into the vessel 
before the current is turned on. The same method with the needle introduced 
into all parts of the dilated sebaceous follicles is said to be effective in reducing 
the hypertrophy of the third stage. When the nodular growths are excessively 
large, amputation may be expedient, as the only way to certainly result in any 
material reduction in the size of the nose. Cases requiring surgical operation 
are of extreme rarity. When papules or pustules become a prominent feature 
of rosacea, local treatment as indicated under the treatment of acne may be 
required. For internal remedies see Agar., Ars., A. Brom., A. iod., Bell., 
Calad., Cal. phos., Carbo anam.. C. veg., Carbol. acid.. Gaust., Coccu. ind., 
Colch.. Kali brom., Nux vom.. Phos. acid. Rhus tox.. Sepia^smd Silica. 



HERPES 

The term herpes has gradually become restricted in dermatology to desig- 
nate a type of acute non-contagious eruption of grouped vesicles, not usu- 
ally occurring in association with other eruptive diseases. The terms 
herpes iris, herpes circinatus and herpes tonsurans, while still employed to some 
extent in text-books, are known, the first as a form of erythema multiforme, 
the last as a form of ringworm, and the second may refer to either disease. 
Here the term will include the two forms of simple herpes, designated accord- 
ing to their location as herpes facialis and herpes progenitalis, while herpes 
zoster and herpes gestationis will be discussed in the same class. 



HERPES FACIALIS 248 

HERPES FACIALIS 

{Herpes labialis; Herpes febrUis; Cold sores; Fever blisters, etc.) 

Symptoms. — This very common Eorm of herpes scarcely Deeds a full de- 
scription. .It often appears after febrile disturbance from some cause, such 
as a catarrhal cold, malarial paroxysm, sore throat, etc., bui is often due to 
non-febrile gastric disorders, and ma; occur without any antecedenl symptoms. 
The usual location is about the mouth or nose, less often on other parts of 
the lace, ears and not infrequently on the mucous surfaces of the mouth, throat 
or nostrils. After more or less distinct sensations of heat, tension, pricking, 
etc., at the point of attack, a sensitive swelling appear.- quite suddenly, which 
in a short time is transformed into papules, and a few hours later into ves 
These are pin head to a small pea in size, full of transparent Berous fluid, and 
arranged in one or more irregular groups of a dozen or less, some of which 
may coalesce and form blebs. Within a few days the vesicles become opaque 
or yellowish, gradually dry up without rupture and form yellowish-brown 
crusts, which fall off in the next few days, leaving the skin intact, but remain- 
ing slightly reddened or stained for a short time longer. If the crusts are 
prematurely torn off, an irritated, oozing surface is exposed. On the mucous 
surfaces herpes is not usually seen in the papulo-vesicular stage, but only 
after exfoliation of the epithelium has occurred, leaving sharply defined, gray- 
ish-white patches known as "canker sores." 

Etiology and Pathology. — The more obvious causes have been pre\ i- 
ously mentioned in the symptomatology. It is not improbable that a sort <>( 
neurotic predisposition may form a part of the etiological chain, so that like 
effects are experienced from different causes. However this may be, it seems 
more than plausible that irritation of the peripheral nerves is an essential 
part of the pathology of herpes. This excitation may be reflected from distant 
organs, arise in the course of a nerve trunk or in the skin itself, but is probably 
most often reflex in nature, involving the sympathetic ganglia through the fifth 
nerve. An attempt has been made to show the parasitic origin of herpes, but 
nothing has been proven. Facial herpes is looked upon by some authorities 
as a modified zoster, but it is clinically quite distinct. 

Diagnosis. — Herpes of the face is only likely to be mistaken for eczema, 
impetigo or zoster. From eczema it is easily distinguished by its larger vesi- 
cles, tendency to dry up without rupture or continuous weeping, and its short 
course. The resemblance to impetigo would be only apparent after crusts had 
formed. In herpes they are less elevated, which, together with the history of 
development from grouped vesicles, would settle the diagnosis. Zostt r is pre- 
ceded or attended with sharp, neuralgic pains, is situated on the lin< 
nerve distribution (rarely on the face), is nearly always unilateral and of 
longer duration, and does not tend to recur. 

Prognosis. — This is good for immediate recovery. Herpes probably 
little significance when occurring in the course of an acute disease. The ten- 
dency to recur is often marked. 



244 HERPES PROGENITALIS 

Treatment. — This is almost wholly by internal remedies selected from 
related gastric or other symptoms (see list of drugs under herpes progenitalis ) . 
Protection may be given to the affected skin and resolution hastened if desirable 
by painting the patches over with collodion, or when crusts have formed, they 
may be removed by applying sweet oil. 



HERPES PROGENITALIS 

(Herpes preputials.) 

As the name indicates, this form of herpes occurs on the external genital 
organs of both sexes. 

Symptoms. — In men the most common seat of the eruption is on the 
mucous surface of the prepuce, but it may occur upon the outer part or at 
any point on the skin of the penis, the glands or even in the meatus. In women 
it is often situated on the labia, clitoris, mons veneris, occasionally on the peri- 
neum, anal and genito-crural regions, and sometimes on the vaginal surfaces 
and os uteri. On the skin of the genital regions the process differs in 
no way- from facial herpes, except as modified by heat, friction or pres- 
sure; but on the mucous surfaces vesiculation is often attended with some 
swelling. There may be but one pin-head sized vesicle, and seldom more than 
one group of vesicles, which look like white spots on the mucous surface. 
These rupture in a few hours, leaving small, raw, grayish, Well-defined spots, 
which, if unirritated by harsh treatment, heal in a few days without loss of 
substance or induration. If, however, the denuded spots are irritated by re- 
peated coitus, caustics, etc., ulceration may follow, perhaps for weeks, masking 
entirely the primary affection and often attended with induration of the in- 
guinal glands. Moderate swelling and tenderness of the inguinal glands may 
occur in susceptible individuals without suppuration. This form of herpes 
tends to recur in some persons of either sex on slight or ordinary provocation. 

Etiology and Pathology. — The most reasonable explanation of the oc- 
currence of genital herpes is, that an acquired susceptibility of the sensory 
nerves of these parts is such that ordinary local factors excite a reflex action 
in the neighboring sympathetic ganglia. This predisposition in men appears 
to often originate from previous venereal disease. Two-thirds of my recorded 
cases show the history of venereal affections. It is not so easy to name a 
probable mode of origin in women unless it be from repeated menstruation, 
which seems rather an immediate than a predisposing cause in chaste women. 
Herpes is more common in prostitutes, probably from the prevalence of vene- 
real disease among them, as well as the frequency of local irritations. The 
predisposition existing, an attack in men is not infrequently brought on by 
sexual intercourse, and in women by menstruation :but hvpera?mia of the genital 
organs from voluptuous emotions, irritations of the bladder or urethra, from 
conditions of the urine, catarrhal discharges, passing the catheter, appears capa- 
ble of exciting outbreaks. 



BERPES ZOSTER 246 

Diagnosis and Prognosis. — If seen early, herpes progenitalis is easily 

[■(•cognized. One or more vesicles on a red base are sufficiently characteristic. 
When the lesion has become excoriated, it may be very difficult to make a 
positive diagnosis at once from the initial lesion of syphilis and chancroid. 
The primary sore of syphilis is usually solitary, slow in development, with 
slight sero\is discharge, an indurated base, and is attended with engorgement 
of the inguinal glands. Herpes vesicles are often multiple, sudden in develop- 
ment, without induration, often without glandular swelling, and may some- 
times he made to discharge a serous fluid by pressure. Chancroid is destruc- 
tive in tendency, auto-inoculable, and produces inflammation and sometimes 
suppuration of the glands of the groin, thus differing from herpes. In a case 
of doubt, a few days' simple treatment will clear up herpes, only modify chan- 
croid, and produce no effect on the course of true chancre. Herpes of the 
genitals opens wide the gates to possible venereal infection, and should, there- 
fore, be kept in mind in cases of probable exposure, both in relation to diag- 
nosis and prognosis. The latter is always good for the immediate recovery 
from an attack, but is rather uncertain in regard to recurrence. 

Treatment. — Absolute local cleanliness by gently washing with soap and 
hot water, followed by dusting the spots with an impalpable powder of boric 
acid, aristol or calomel, is the only immediate treatment needed in most cases. 
When the affected part is exposed to friction, a ten per cent, ointment of either 
boric acid or aristol may be found serviceable. Treatment should he addressed 
to a correction of the predisposition to herpes as well as to the immediate 
attack. Prophylactic measures can be enhanced by the local use of tannin 
and brandy or aromatic wine plus a sexual hygiene aimed at the prevention of 
genital congestion. 

For internal medication see indications for Ars., Ganth., Garbo veg., Cistus, 
Olemat., Gornus tire. Grot, fig., Dulc. Hcpar, Nat. mur., Sepia, Sal.. Tere- 
binth., Thuja, and Urtica urens. 



HERPES ZOSTER 

(Zoster; Zona; Ignis sacer; Shingles.) 

Definition. — An acute vesicular eruption situated on a red base, and 
distributed along the line of one or more cutaneous nerves. 

Symptoms. — Premonitory pains of a variable neuralgic nature nearly al- 
ways precede the eruption for a few hours or days. Occasionally the pains 
begin coincidently with the eruption, and rarely may continue or follow its 
decline. The neuralgic pains may be limited to definite points or more or less 
diffused about the region to be invaded, and often points sensitive to pressure 
may be found somewhere in the course of the nerves. When the attack is to 
occur on the side of the trunk, as commonly, the point of greatest tenderness 
is usually near the exit of the posterior spinal nerve adjacent to the vertebra. 
The eruption begins with some redness of the skin followed in a short time by 



246 "HERPES ZOSTER 

groups of acuminate, closely placed papules, which within a few hours are 
converted into pin-head to pea-sized vesicles, fully distended with clear serum. 
These may remain distinct and clearly outlined by the erythematous skin about 
them, or some may coalesce forming bullae. Prickling, tingling or smarting 
sensations generally attend the development into vesicles. After remaining 
clear for two to four days without tendency to rupture, the vesicles slowly 
become opaque, dry up into yellowish-brown crusts, and finally fall off, leaving 
a slight redness to slowly disappear. Barely there may be left some persistent 
pigmentation at the site of the lesions. Such is the course of one group of the 
eruption, with an average duration of about ten days; but as the eruption ap- 
pears in successive crops, a few hours or days apart, and all the patches pass 
through the same course, the duration of an attack may be prolonged to from 
three to six weeks, and rarely longer. The groups of eruption vary widely in 
size from half an inch to four or five inches in diameter. They are irregular in 
shape, but tend as a whole to form a semi-band like distribution on one side of 
the trunk, which usually beginning nearest the spine extends successively more 
or less forward toward the median line, and occasionally slightly beyond. Some- 
times the distribution is more uniform over a small or larger extent of surface, 
or a narrower irregular linear arrangement of lesions is seen. In all regions 
the distribution is almost invariably unilateral, but a few cases of bilateral 
zoster have been reported. One of double cervical zoster was recently under my 
observation for four weeks, the distribution being on a level and about equal on 
both sides. The onset and duration were otherwise typical. 

Most cases of zoster follow a rather uniform course as already described, but 
occasionally anomalous cases are seen. Perhaps the most common departure is 
by slight hemorrhage occurring in some of the vesicles which does not usually 
affect the course of the attack. Barely all the lesions become hemorrhagic, rup- 
ture and lead to ulceration ; exceptionally they become gangrenous at the base, 
zoster hemorrhagicus and gangrenosus respectively. These variations in the 
disease result in destruction of tissues with consequent scarring and rarely 
keloidal growths. The cases of this kind seen by the author were nearly all 
hospital cases, and more or less anaemic or cachectic. Sometimes swelling of 
the subcutaneous glands in the neighborhood of zoster has been observed. 
Occasionally in old people zoster may assume a chronic tendency. Such an 
instance of supra-orbital zoster was seen by the writer recently, in which a few 
vesicles appeared in crops every three or four days for three months, always 
preceded by the characteristic neuralgic pain. A few of the lesions went on to 
ulceration. On the other hand, the eruption of zoster may be arrested in the 
papular stage and resolution occur without vesiculation, abortive zoster. 

The eruption of zoster may be located along the distribution of any cuta- 
neous nerve, though it shows a marked preference for the nerves of the trunk, 
especially on the right side. More than half of all cases appear upon the trunk. 
Next in order of frequency are the cervical, the region supplied by the fifth 
nerve, abdomino-crural region, leg, arm, etc. As branches of several nerves 
may communicate with the same ganglion, if the latter is affected, the lesion 






Fig. 67.— HERPES ZOSTER 
(Left side of neck) 




Fig. 68.— HERPES ZOSTER 
(Right side of neck) 

BILATERAL RECURRENT VARIETY 

Patient is a neurotic, middle-aged man with a history of five previous bilateral 
attacks. Disease began first on the right and later on the left side of neck with 
sharp neuralgic pains radiating into shoulders and head, attended with anxious n st- 
lessness, chilliness and thirst; these continued in lessening degree to the lull devel- 
opment of the eruption. Physical weakness, restlessness (especially at night), to- 
gether with local tension and itching, were prominent symptoms of later course. 
Lesions consist of well-filled vesicles on an erythematous base and arranged in lines 
or groups. Cured with aconite, third decimal, and rhus tox., second decimal. No 
recurrence in past ten years. 




Fig. 69.— HERPES ZOSTER 

INTERCOSTAL VARIETY 



Patient is a man of twenty-seven, very anaemic, and of a neurotic type. He 
first complained of pains under the left shoulder blade, which disappeared when he 
moved about. Two days later grouped vesicles on an erythematous base appeared. 
Fresh crops developed until the lesions extended from the spine in the rear to the 
sternum in front. Cured by rhus tox.. third decimal. 



HERPES ZOSTER 247 

may appear ou any of the distal lines of the several nerve fibres. The nerves 
of two or more adjacent regions may be simultaneously involved and rarely 
separated districts may be attacked at the same time. Single or combined 
names of anatomical regions have been employed to designate the Localization 
of zoster, such as zoster fro nlalis. cervicalis, brachialis, pectoralis ( intercostal is ). 
cruralis, genitalis, cervico-bronchialis. lumbo-ingmnalis, sacro-genitalis, etc., 
etc. When the fifth nerve is affected there may be considerable variation in the 
clinical expression. Most often the frontal branch is chiefly involved, and the 
eruption in the supra-orbital region may extend upon the scalp. If the 
ophthalmic divison of the nerve is irritated, zoster ophthalmicus, there is 
corresponding involvement of the eye, such as conjunctivitis, distension of the 
blood-vessels; sometimes papules and vesicles form on the cornea followed by 
ulceration, or iritis may occur, and in some of these ways result in permanent 
defect of the eye. These cases are always attended with pain and danger, even 
when the eye itself is not seriously affected. In some cases the swelling of the 
skin and subcutaneous tissue of the eyelid and brow may completely close the 
eye, simulating somewhat the objective appearance of erysipelas. If the second 
branch of the fifth nerve is affected, herpetic lesions may appear on the mucous 
membrane of the mouth and throat of the same side, and subsequent falling 
out of some of the teeth in the affected region has been observed, as well &3 
necrosis of the jaw in one instance. The disease rarely appears below the knee. 
Zoster, as a rule, occurs but once in a lifetime, yet there have been a few 
notable exceptions recorded, the principal one by Kaposi, who mentions 
nine attacks of zoster in the same patient under his observation and two later 
abortive attacks. He places the case in the category of zoster hystericus or 
atypical zoster. I have attended a gentleman of a rather neurotic temperament 
through two attacks of zoster, who gives a clear history of at least six marked 
recurrences. One of these occurred at fourteen while in Europe, and was under 
the observation of Hebra. Ordinarily zoster is a benign disease ending in com- 
plete restoration of the structure and functions of the skin, except the scarring 
after severe hemorrhagic zoster already named. But occasionally abnormal 
sequela remain in the form of sensor, motor or trophic disturbances singly or 
combined. There may be in the region affected by zoster diminished - 
bility only, or some of the various forms of morbid sensation: even complete 
anaesthesia of individual forms of sensation may exist with hyperesthesia or 
paresthesia of a different form (anaesthesia dolorosa). Xeuralgia is not in- 
frequent, especially after facial zoster, and may be far more health disturbing 
than the original disease. Neuritis, fortunately, does not often occur. From 
the records of about one hundred cases the editor has noted only one instance 
of this disease following zoster. The function of motor nerves in or near the 
region of zoster may be interfered with and show in paralysis or muscular 
atrophy. Most cases were probably temporary in duration, but Besnier men- 
tions one case of permanent facial paralysis. Among trophic effects, l< 
teeth before named, falling out of the hair, interference in the nutrition of the 
nails, and at least two cases of unilateral hyperidrosis have been attributed to 
zoster. 



248 HERPES ZOSTER 

Etiology and Pathology. — More than half of all cases of zoster occur 
before the twentieth year of life. It is rare in infants, though a case has been 
recorded by Loiner occurring in a child only four, days old. The disease is 
rather more common in adults after middle life than before. It occurs more 
often in spring and autumn than at other seasons, but this may be due to the 
more frequent variations in temperature than at other times of the year, as 
cold or chill has been often noted as an exciting cause; among other direct 
causes are traumatisms — accidents, extraction of teeth, vaccination, surgical 
operations, etc. — neoplasms, abscess, pleurisy, and other sources of peripheral 
nerve irritation. The operation of some, if not all of these factors, implies an 
abnormal susceptibility or irritability in the nerves of the regions about to be 
attacked, for generally acting causes of different kinds seem to produce like 
results. Thus inhalations of coal gas and its diffusion in the blood have brought 
on attacks of the disease. Zoster following the administration of arsenic has 
been noted, too frequently to be explained as a mere coincidence, especially in 
view of the well-known affinity of this drug for the peripheral nerve termina- 
tions. The causal influence of functional nervous perversion like hysteria, or 
mental depression and excitement, can only be explained on the same basis. 
Herpes zoster is not uncommon in tuberculous subjects and in those suffering 
from the constitutional effects of cancer or other cachexia. It has occurred 
epidemically, alone or in association with some epidemic disease like influenza. 
Owing to this fact and to very clear evidences of direct contagion in a few cases. 
and to the immunity from a second attack enjoyed by most patients, the belief 
is steadily growing that zoster may be. at least in some cases, an infectious 
disease. It sometimes appears due to reflex effects from irritation of internal 
organs, and in not a few cases no cause is apparent. In the pathology of zoster, 
micro-organisms are believed by some to be the prime cause, either through 
invasion into the tissues of the part affected, or by special microbic infection 
resulting in toxic effects on the nerve centres. These suppositions are. as yet. 
unsupported by scientific proof and do not harmonize with the clinical history 
of many cases of the disease. The real pathological cause of zoster is un- 
doubtedly disease of the nerve which is distributed to the affected skin, either 
at its origin in the cord or in the ganglion, or in its course outward to the sur- 
face. The kind of nerve change may vary also in different cases, though 
neuritis of some part of the nerve tract is probably the most common. This 
takes the form of interstitial neuritis of the ganglion in most cases, as first 
demonstrated by Barensprung in 1862 : hut it has been shown since that the 
neuritis may affect any intermediate part of the nerve or its cutaneous divisions, 
leaving the ganglion intact. If the neuritis involve the motor branches, muscu- 
lar paralysis may accompany or follow the eruption. "When peripheral neuritis 
and consecutive herpes arise from external injuries of various kinds, the deeper 
nerve structures are not usually affected. Least of all. inflammation of the 
posterior columns of the cord and cerebral disease have been observed in asso- 
ciation with zoster. Pressure from hemorrhage into the ganglion, nerves or 
sheaths; from tumors, abscess, blood clots, etc., adjacent to nerve trunks or 






HERPES ZOSTER 249 

branches, are some of the non-inflammatory causes which have produced a 
irritation, with resulting inflammatory effects of the skin. Whatever the 
pathological cause may be, the effect on the nerve distribution is usually of a 
temporary nature, and hence is not followed by a recurrence of the cutaneous 
manifestations. When the effect is extreme, hemorrhage, necrosis, etc., may 
take place in the lesions; and when more persistent, some of the Bequelaa may 
follow, such as sensory or motor disturbances occasionally seen. Considering 
the fact that all spinal nerves are complex and contain sensory, motor, vaso- 
motor and possibly independent trophic fibres, it is remarkable that zoster so 
often pursues a typical course. At the same time this may account for the 
differences of opinion as to whether it is a sensory, vaso-motor or trophic neu- 
rosis. The anatomical changes in the skin are essentially the same as occur in 
other vesicular diseases, the lesions originating in the deeper portions of the 
rete. The one peculiarity of the zoster vesicle is found in its walls, which con- 
tain epithelial cells transformed into round or ovoid bodies. These bodies are 
larger than normal cells and contain from two to a dozen round bodies. 

Diagnosis. — Little trouble will be generally found in recognizing herpes 
zoster, if its characteristics are remembered. The associated neuralgic pain, 
successive eruption of crops of vesicles on an erythematous base, distributed 
along the course of cutaneous nerves, and almost always on one side only, are 
peculiarities not exhibited by any other disease. The comparative differences 
from simple herpes have been stated in the diagnosis of herpes facialis. The 
vesicles of eczema are smaller, soon rupture, and tend to produce a continuous 
discharge, and are attended with greater pruritus. 

Prognosis. — Keeovery is to be expected in nearly every case of herpes zos- 
ter. Successive crops of vesicles may prolong an attack beyond the average 
duration of two or three weeks. In ophthalmic zoster the possibility of result- 
ing damage to the eye and scarring in tin's and the hemorrhagic form should 
be borne in mind. 

Treatment. — Most cases require no local attention aside from simple pro- 
tection with a rather thick layer of sterilized cotton or gauze held in place by 
a bandage. If there is much heat, stinging or burning, four or five thick* 
nesses of gauze may be wet with alcohol and laid over the patches with the 
protecting cotton-wool outside. When severe pain continues with the eruption. 
tincture of hypericum one part to two parts each of alcohol and water may he 
employed as directed, or alcohol alone. When neuralgic or neuritic pains per- 
sist after the eruption has subsided, the high frequency currents can he used 
by means of the vacuum electrodes. Painting the lesions with simple collodion 
sometimes gives efficient protection and probably hastens resolution. The 
author has rarely found anodynes locally or internally accessary in the treat- 
ment of zoster. Protection of the affected surface and the indicated remedy 
have almost invariably afforded reasonable relief and hastened cure. For in- 
ternal remedies see indications for Aeon., Ars., Aster, rub.. Bell., Canth., Gistus 
dr., Colch., Croion tig.. Dale. Graph.. Hyper., Tri.< ver., h'"H brom., Kolmia, 
Lach.. Mez., Paris quad.. Rdnun. bulb., Rhus lor.. SiL, Spigelia. 



250 DERMATITIS HERPETIFORMIS 



DERMATITIS HERPETIFORMIS 

(Hydroa herpetiforme; Herpes gestationis; Pemphigus pruriginosus ; Pem- 
phigus circinatus bullosus; Hydroa bullosus, etc.) 

The partial list of synonyms here given indicates the varied clinical forms 
of a cutaneous disease which may be said to be all variety rather than one dis- 
tinct type with variations therefrom. The unification of the different forms 
under the above caption is due to Duhring, whose investigations and con- 
clusions have been generally accepted by dermatologists. Kaposi, however, 
does not view it as an independent disease, but rather as related to, or aa 
variations of pemphigus, except a form now described as impetigo herpetiformis. 

Definition. — An infrequent cutaneous disease, characterized by a 
variable and often mixed eruption of papules, vesicles, bullae and pustules, 
with associated erythema ; commonly arranged in groups, chronic in course 
and usually attended with marked sensations of itching, burning or tension. 

Symptoms. — Moderate constitutional disturbances, such as anorexia, con- 
stipation, chilliness, feverishness, etc., may precede the onset of the eruption 
or its aggravations during the course of the disease. These may continue for 
some days after the eruption appears. In not a few cases the systemic dis- 
turbance is very slight or absent, while in severe cases it may be well marked 
and persistent. More or less pruritus may be felt in the skin for a few hours 
or days before the appearance of the eruption, or the latter may occur suddenly 
without local warning of its approach. It is bilaterally and often symmetrically 
located, most often on the flexor surfaces of the wrists, forearms, the abdomen, 
buttocks, and outer part of the thighs, but it may be generalized over the whole 
surface or limited without rule to any region. The lesions tend to occur in 
groups of two or more, and singly or combined from unusual and varied shapes. 

The vesicular form is often the earliest as well as the most common and 
characteristic type of the disease. The vesicles vary in size from a pin head to 
a pea, and when situated in clusters on an erythematous base closely resemble 
groups of herpes simplex or zoster. They show their further herpetic nature 
by not rupturing spontaneously. The earlier vesicles after a time dry up and 
form scabs, while the later lesions are more apt to coalesce and form bullae, 
which in time shrink up and if undisturbed leave peculiar puckered brownish 
crusts. In many cases the vesicles are attended with redness, and sometimes 
when small and translucent may remain undiscovered. They are more often 
yellowish or pearly in color, and occasionally the contents of some become 
opaque or sero-purulent. Many of the lesions may vary in outline or form; 
they may be oblong, angular, stellate, semi-spherical or rarely circular. These 
and the tendency to occur in groups of two, three or more, or in bead-like lines 
form incomplete, irregular or multiple circles situated on normal, reddened or 
inflamed skin, and sometimes an intermingling of blebs, papules and pustules 
in various stages of evolution present an unmistakable picture of this disease. 
The eruption may continue to appear in frequent crops, or at longer intervals 




Fig. 70.— DERMATITIS HERPETIFORMIS 
(Herpes Gestationis.) 

VESICO — BULLOUS VARIETY 

Patient is a young married woman in the sixth month of her third pregnancy. Since 
twelve she has suffered from neurotic disorders, but has improved in health with her two 
former pregnancies. Disease began four months ago, about two months after conception, 
and has been attended with progressively severe and unbearable sensations of tension, 
smarting and itching. The lesions consist of vesicles and bulhe varying from a half pea to 
a walnut in size, discrete or grouped, and leaving as they dried up patches of inflamed 
skin on which similar lesions repeatedly developed, sometimes encroaching on the sound 
skin at the border in the form of small vesicles or larger blebs. The eruption is chiefly 
confined to the legs and abdomen. Cured with arsenic. (Courtesy of Dr. \V. S. Garnsey). 



DERMATITIS HERPETIFORMIS 261 

i'or weeks or months, until after a variable period remission or intermission 
interrupts the course of the disease, for a longer or shorter time. '\YTien the 
outbreaks are frequent and the itching intense, the skin is likely to become 
infiltrated and excoriations may be added to or change other lesions. With the 
disappearance of the lesions, slight pigmentation may remain for a time to 
mark their former sites. 

The bullous form may develop from vesicles, erythematous patches, or arise 
from the sound skin, and exhibit lesions varying in size from a pea to a hen's 
ally or partially distended with clear milky or sero-purulent fluid. Within 
a few days they are likely to be ruptured by scratching or otherwise, and then 
dry into yellowish-brown crusts which after a time fall off, leaving the skin 
hyperaemic or stained. Vesicles and pustules as well as erythema may mingle 
more or less with the bullous lesions, and sometimes the type gradually or sud- 
denly changes to the mixed or other form of eruption. 

An erythemato-papular form may be primary or secondary to other types 
of the eruption. Erythematous lesions quite commonly predominate in the 
eruption and occur in association with other types, but the papular very rarely 
exist alone or even characterize the efflorescence except in moderate association 
with erythematous or vesicular lesions. The onset and course of the erythemato- 
papular eruption is often acute or subacute, and appears in small or larger 
pinkish patches which later become yellowish-red. These may be sharply de- 
fined or fade into the adjacent skin, or mingle with maculo-papules and wheal- 
like elevations, and sometimes cedematous swellings. The eruption occurs in 
crops, tends to persist, and is frequently widely distributed. On a single 
region the resemblance to erythema multiforme may be exceedingly close. 
Sometimes isolated groups of distinct, large or small papules are seen, though 
seldom many or freely distributed. They may be flat, round or irregular in 
shape, slow in their course, often excoriated from efforts to relieve the intense 
itching, and, finally, when they fade away leave behind some pigmentation. 
Vesicles may develop on some of the lesions of the erythemato-papular form, 
or it may preserve its type throughout an attack and after a longer or shorter 
quiescence recur again and again in the same or other forms of the disease. 

The pustular form of dermatitis herpetiformis is so rare and so nearly 
approaches in clinical type impetigo herpetiformis that its identity as a dis- 
tinct variety is in doubt. The most that can be said is that in some cases there 
is a predominance of pustular lesions, arising primarily as such, or developing 
from pre-existing vesicles or papulo-vesicles, and nearly always intermingled 
with these and the lesions of other forms. The pustules vary in size, mature 
in from five to ten days, but new lesions arise singly or in crop.-, and prolong 
the attack for an indefinite number of weeks. Aside from those features and a 
less tendency to grouping and diversity of arrangement of lesion? than in the 
vesicular form, the course otherwise is much the same as in the latter variety, 
always, however, indicating a graver general condition, and usually attended 
with greater systemic disturbance. The mixed form is frequently a transitional 
variation from one of the foregoing forms to another, or it may be a mingling 



252 DERMATITIS HERPETIFORMIS 

more or less of the lesions of all forms, but a distinct mixed type is seldom 
persistent. 

Dermatitis herpetiformis occurring during or soon after pregnancy has been 
sometimes described separately as herpes gestationis. Its only other dis- 
tinctions appear to be that it disappears at the end of the parturient period as 
a rule, but has a great tendency to recur at each successive pregnancy with in- 
creasing severity, and finally to assume the course of other forms of dermatitis 
herpetiformis. 

Etiology and Pathology. — The disease affects both sexes and may occur 
at any age, but is most often seen in the first half of adult life. Many attacks 
have followed antecedent nervous prostration, mental worry, shock, emotional 
disturbances, and from exposures, all suggesting a neurotic origin. Any cause 
which sufficiently disturbs the nutritive processes in the skin may give rise to it 
without much or any systemic disturbance. In other cases it seems to originate 
from some general lack or derangement of nutrition. Winfield has reported a 
number of cases associated with glycosuria, and a few cases ending fatally have 
been recorded as due to septicaemia. 

The pathology is intimately related to that of erythema multiforme, urti- 
caria, herpes zoster and pemphigus, and presents an acute inflammatory condi- 
tion of the corium. especially of the papillary layer. There is the usual dilata- 
tion of vessels, oedema and infiltration of lymph spaces. Vesicles form rapidly 
between the basal layer of the rete and papillary body. These vesicles may 
coalesce to form larger ones and contain a network of fibrin with red-blood, 
epithelial, mononuclear and eosinophile cells. These last, Lerrede believes, are 
peculiar to dermatitis herpetiformis and similar diseases. The lesions of der- 
matitis herpetiformis are always superficial and never tdeerate, and hence do 
not leave cicatrices (unless caused by secondary infection). Pigmentation 
sometimes follows, but though it may be persistent, it is probably never per- 
manent. 

Diagxosis. — An accurate history of attacks and their course will be of 
great service in differentiating dermatitis herpetiformis from other affections 
which exhibit similar eruptions. Thus the more general differences from 
eczema, pemphigus, herpes zoster, erythema multiforme and urticaria will be- 
come manifest. In eczema the vesicles are smaller, more regular in shape, less 
grouped soon rupture, and give rise to continuous discharge and crusting. The 
papules of eczema are also smaller, regular in size and shape, not tending to 
appear in groups, as in the case of dermatitis herpetiformis. Pemphigus bulla? 
usually arise from the sound skin, are commonly larger and more regular in 
outline than the bullous lesiou of dermatitis herpetiformis, do not show a 
tendency to become grouped or commingle with other lesions and do not cause 
itching, as a rule. Herpes zoster would scarcely be mistaken for dermatitis 
herpetiformis. Its limited distribution, neuralgic sensations, definite course 
and unilateral location clearly distinguish it from the latter. Erythema multi- 
forme and the erythemato-papular form of dermatitis herpetiformis may be 
very like in their objective appearance, but the former is usually limited to the 



DERMATITIS HERPETIFORMIS 268 

back of the hands, arms and face, is not attended with Intense itching, and runs 
an acute course in from ten to twenty days. If vesicles or bulla; appear fchey 
are always consecutive to erythema, which is not always the case with the 
vesicular lesions of herpetic dermatitis. Urticaria will seldom he confounded 
with dermatitis herpetiformis. Its usual onset with a sudden eruption of 
ephemeral wheals with the mixed sensations of stinging and itching, without 
tendency to become grouped or arranged in broken or more complete circles, 
and the absence of multiform lesions are distinctive. 

Prognosis. — The capricious nature and course of this affection render it 
impossible to predict with any certainty the future of any case. It is only in 
the most severe cases that the general health is affected, so the prognosis is 
usually good so far as danger to life is estimated. Most cases may be expected 
to recover ultimately under appropriate treatment, but the liability of all ordi- 
nary forms of the disease to be capriciously chronic in one or variable type- is 
to be kept in mind in estimating its course. Of the nine cases lately treated by 
the authors, three have died, one of these being seventy years of age and the 
other two having had the disease for years previously. 

Treatment. — As the normal functions of the cutaneous nerves are evidently 
interfered with in this disease treatment must be directed to the abatement or 
removal of the underlying causes of the nerve derangement. Causal and physi- 
ological methods may be required to bring the system into a better condition 
of nutrition and restore the nervous equilibrium. Frequently benefit will be 
experienced by a change from an animal to a vegetable diet and an interdiction 
of such nerve disturbers as coffee, tea, alcoholic stimulants and tobacco: hut 
these and other needs will be apparent in a given case and need not he ap- 
proximated here. The employment of an' indicated drug may he the most im- 
portant of all treatment, and in all cases will aid in giving relief from the in- 
tense itching as well as assisting in the cure. Often the relief experienced from 
internal remedies will render unnecessary any but the simple local means of 
cleanliness. Frequent hot baths in water made slightly alkaline with bicarb- 
onate or biborate of soda or saline with ordinary salt will he found helpful. 
Longer baths of twenty to forty minutes may be serviceable in severe cases, and 
the continuous bath has been recommended for aggravated forms. If large 
blebs form they may be punctured before the bath to give greater ease from 
the itching; and occasionally a mild boric acid ointment applied after the hath 
will be found comforting. General galvanization and the use of the mild high 
frequency currents have been useful in the milder forms of this disease. Among 
the lotions recommended, liquor carbonis detergens (one part to ten to one 
hundred of water), or the permanganate of potash (1:2000) .are the 
The latter has, however, many well-known disadvantages and cannot be urged 
except in extreme cases. Among internal remedies see Ant. tart., Carbol. acid, 
Clematis, Croton tig.. Iris vir., Kali brom.. K. iod.. Lack.. Xat. mur.. Phos., 
Ranun. bulb.. Rims tox., Sepia, SiL, Tellurium. 



254 IMPETIGO HERPETIFORMIS 



IMPETIGO HERPETIFORMIS 

Definition. — A rare affection of the skin, in which an eruption of 
miliary pustules occurs in groups, usually during pregnancy, and is at- 
tended with severe constitutional symptoms. 

Of the thirty odd recorded cases of this disease, few have been observed in 
this country, and Crocker states he is not aware that any case of the disease has 
been recorded in England. Kaposi who has observed most of the cases be- 
lieves it to be a disease sui generis. It is chiefly from the latter's description 
(Dis. of the Skin, 1895) that the following account is taken: The disease 
comes on with chills and high fever, dry tongue, vomiting and some delirium, 
and these appear or are aggravated before fresh outbreaks of the eruption ; the 
accompanying high temperature remaining continuous or remissions intervene. 
The eruption appears in patches from the size of a lentil to that of a penny, and 
consists of pinhead pustules, opaque at first and later greenish-yellow, situated 
on a red and slightly swollen base ; on the first or second day they dry into dirty 
brown crusts, and new pustules form around them in one or more closely placed 
circles ; these in turn dry and add to the central crust. Thus the patches, usu- 
ally beginning first on the inner aspect of the thighs, groin, axillae, around the 
navel, etc., may spread over large areas and merge with adjacent patches until 
at the end of three or four months the entire surface may be involved. The 
skin is hot, swollen, more or less covered with crusts, or denuded and oozing as 
in eczema, smooth or uneven, but never ulcerated, while excoriations and fis- 
sures may be found in places still bordered by circles of pustules. In some cases 
the mucous lining of the mouth and throat contains circumscribed gray patches 
with a depressed centre, and in one autopsy pustules and small ulcers were 
found on the folds of the oesophagus, most numerous near the cardiac portion 
of the stomach. 

Etiology and Pathology. — These are obscure. The fact that nearly all 
cases have occurred in pregnant women shows the existence of some factor 
favored by the condition of the system during the period of gestation, and that 
the pathology may be akin to herpes gestationis. The further fact that there 
was an absence of septic, uterine or other disease in most cases certainly sup- 
ports the supposition that it is reflex in origin and trophic in results on the 
skin. Evidences of nephritis and phthisis have been discovered on post-mor- 
tem examination. The blood and lymph vessels show dilatation, with swollen 
cells in and about them, especially in the papillary layer beneath the pustules. 

Diagnosis would not ordinarily present any difficulties, especially if the 
patient was a pregnant woman. The diagnostic points are the occurrence of 
grouped pin-head, yellowish-green pustules drying into darker crusts, with 
successive growth by the formation of new pustules in circles immediately 
around the preceding lesions, the sites of preference and the continuous spread- 
ing therefrom, the marked constitutional symptoms named above, and the 
almost certain tendency to a fatal termination. Absence of multiform lesions 




Fig. 71— DERMATITIS REPENS 

CHRONIC VARIETY OF OUTER SURFACE OF RIGHT ANKLE 

Patient is a well nourished woman, aged sixty-six. Disease began five years 
ago as a pea-sized bleb (probably induced by friction of boot-top) , which after rup- 
ture continued to exude a watery fluid. This increased as the inflammation spread 
laterally and upwards and has at no time ceased. Burning or smarting sensations 
have always been worse at night, especially after sleep. The lesion consists of a 
denuded area about three inches in diameter, with an elevated sodden border, at 
some parts undermined, at others sloping towards an intensely red center or base. 
The latter is constantly bathed with a watery secretion only, which at night with 
the leg in a horizontal position, overflows and gives to adjacent skin a macerated 
appearance. Greatly relieved and improved while using Icchesis, thirtieth decimal. 



DERMATITIS REPENS 

and a more uniformly persisted course Mould distinguish it from dermatitis 
herpetiformis. In its advanced stage it might be confounded with pemphigus 
vegetans, but the history of the onset of the hitter by a bullous eruption, or the 
former by grouped pustules, would be distinctive. 

So far the prognosis has been very grave. Of fifteen cases mentioned by 
Kaposi thirteen died. 

The treatment is practically on the same lines as outlined for dermatitis 
herpetiformis, with the selection of a drug to meet the constitutional symp- 
toms. The uterus should be emptied of its contents. 7ns ver., Clematis, Groton 
tig., Kali orom., Lach., and Nat. mur. are remedies most likely to be indicated. 



DERMATITIS REPENS 

This peculiar form of dermatitis was first described by Crocker in 1888 
from the observation of three cases, He defined it as "a spreading dermatitis, 
usually following injuries, and probably neuritic, commencing almost ex- 
clusively in the upper extremities." According to Crocker, who has treated a 
dozen cases, the disease begins with a "free exudation of fluid in the form of 
vesicles or bullae, the result of which is the complete denudation of all the 
upper layers of the epidermis and leaving an intensely red surface oozing at 
numerous points. Occasionally when the process is subacute visible exudation 
may be slight or absent; the border consists of the epidermis undermined and 
raised up by fluid exudation, and is usually sodden. The disease spreads by 
direct extension, not by the formation of fresh foci either near or away from 
the original morbid area. It may extend over a part or the whole of a limb, 
or even a portion of the body, and is not accompanied by marked itching, burn- 
ing or disturbance of the general health. Finally, though very rebellious to 
treatment, it ultimately yields to local remedies of an antiseptic character." A 
case of my own began with a small blister on the right leg which developed into 
an epidermic ulcer and slowly enlarged, resisting all treatment for five years 
before she appeared at the clinic. Then there was found a roundish ulcer about 
three inches in its longest diameter with an intensely red, flat, uneven base, 
from which there persistently oozed a watery fluid. The objective appearance 
of the lesion alone was strikingly like a rodent ulcer. A careful microscopic 
examination of sections from the base and indurated border, however, showed it 
to be a purely inflammatory process, which had resulted in denuding all the 
upper layers of the epidermis. There was no local varicosis, and examination 
of the heart, lungs and of the urine gave negative results. The patient was 
well nourished. Therefore no change was suggested in her diet or mode of 
life, and she was permitted to continue the same local dressing. The marked 
aggravation of burning sensations after sleep and the local tenderness led to a 
prescription of lachesis 30. This drug gave her almost magical relief from l ho 
severe nocturnal pains which had deprived her of much sleep for years, and led 
to almost immediate local improvement, noticeable to all who saw her, ami 



256 DERMATITIS REPENS 

which continued with short interruptions for about three months, and she 
seemed then fairly on the way to recovery. At this time the patient was at- 
tacked with pneumonia and did not return to the clinic. 

Acrodermatitis perstans, a condition similar in location, origin, lesions 
and clinical history to dermatitis repens, has been described by Hallopeau, 
Andry and others. Its characteristics are the frequent appearance of secondary 
eruptions, chiefly pustular, on portions of the body distant from the seat of 
original infection, its frequent reappearance in the same place, its persistence 
and possible fatal termination. 

Etiology. — It would appear that most cases originate from some local 
traumatism, however trivial, causing neurotic disturbance and the resulting 
changes in the skin. The following injuries have been noted as occurring prior 
to the disease, at or near- to its point of beginning : a superficial wound of hand 
with dislocation of thumb from a fall, injury of hand necessitating amputation 
of a finger, superficial burn of the hand, an abrasion of the knuckles, a splinter 
run under the nail, an injury of shoulder, arm and hand, an injury to the sole 
of one foot, a scratch of a finger from a bone, and in the same patient at another 
time, from tearing away a finger nail. A case of the editor's exhibited at the 
Flower Hospital, followed repeated pricks on the index finger from a needle. 

Pathology. — The morbid process appears to be due to a peripheral neu- 
ritis set up by an injury, no matter how trivial. While secondary parasitic in- 
fection is generally admitted to be responsible for the prolonged course of these 
diseases, Hallopeau regards both as purely microbic. The staphylococcus albus 
has been frequently found in the lesions. 

Diagnosis and Prognosis. — Dermatitis repens should be easily diagnosed 
from eczema by its elevated, abrupt and advancing border producing the ap- 
pearance of a superficial ulcer. Prom syphilis, lupus and epithelioma, the 
nature and abundance of the exudation together with the absence of diagnostic 
signs of those diseases would be sufficient for differentiation. An investigation 
of the microscopic anatomy of the lesions might be necessary in some cases. 
The same general diagnostic remarks may be made of acrodermatitis perstans. 
Complete recovery may be expected except in severe cases of the latter disease. 

Treatment. — Among the antiparasitic applications recommended are a 
ten per cent, ammoniated mercury ointment, ten per cent, solution of the 
permanganate of potash, and saturated solutions of sodium hyposulphite or 
pyoManin-blue. It is wise to cut away the undermined epidermis and thor- 
oughly cleanse the affected surface with weak solutions of electrozone or hydro- 
gen peroxide before applying the antiparasitics. Carbol. acid. Hepar. Lach.: 
Merc, viv., and Ranunc. bulb, are the most likelv drugs. 



PELLAGRA 

PELLAGRA 

(Lombard;/ erysipelas; Lombard y leprosy} Lepra Italicaj La rosa.) 

This is a trophoneurotic affection which was first observed in Spain over a 
hundred and fifty years ago, and yel continues endemic in the northern part of 
that country, central Italy, Franco, Portugal. Egypt, .Mexico and Roumania. 
In the last named country, according to Morris, in 1888 out of a total popula- 
tion of about five million, over ten thousand were Buffering with pellagra. No 
cases have been reported in this country. The disease usually begins in the 
spring, and is believed to be due to the toxic effect on the nervous system Erom 
eating diseased maize; this producing disturbances in the cerebro-spinal, 
digestive and cutaneous spheres, and in a variety of tonus. One of the earliest 
symptoms is paresis of the lower limbs. This may be preceded or accompanied 
by pains in the joints, burning in the back, and gastro-intestinal disturbance* 
such as anorexia, thirst and diarrhoea. The cutaneous changes begin with a 
deep red or brownish erythema on parts most exposed to the sun. This is 
attended with itching, burning and some swelling. Petechia' are frequent and 
bullae may form, rupture and leave ulcers. In two or three weeks desquamation 
follows, leaving the exposed skin pigmented. Toward the end of the summer 
the disease subsides to recur again in the following spring; thus the attacks 
may appear annually for five or more years, the skin becoming more thickened 
and deeply pigmented for the first few years. If the patient lives on subject 
to the annual recurrences, after five or six years atrophy of the skin f< 
it becomes dry and shrunken as in old age. Even before this period the patient 
may become emaciated, weak, suffer from pain, severe headaches, disturbances 
of vision, colliquative diarrhoea and from an increase of cerebro-spinal symp- 
toms. Unless relieved, sooner or later stupor, delirium, melancholia, suicidal 
mania, etc., together with motor paralysis of the limbs, bladder, etc., are likely 
to occur. In this deplorable state the victim passes away, or some intercurrent 
affection of the heart or lungs hastens a fatal issue. The duration for mild 
cases is rarely more than fifteen years. 

Etiology probably includes the predisposing factors of poverty and igno- 
rance with the attendant lack of nourishment and ordinary sanitation. The 
essential cause is the continued use as a food of unsound or decomposing maize 
which contains or develops a toxic substance. Both sexes are liable to contract 
the disease and heredity may exert an influence, especially if the systemic 
nervous symptoms are pre-eminent. 

Pathology. — Whether the toxin or germ is developed in the maize or in 
the tissues of the body is unknown. Examinations of the fungi found in the 
grain show them to be harmless, and post mortems have yielded various fatty, 
atrophic, cirrhotic and sclerotic conditions of the viscera. Symmetrical scle- 
rosis of the posterior columns of the spinal cord is the most constant morbid 
process. 



25« ACRODYNIA 

Diagnosis must be based on its endemic character and in many cases upon 
systemic symptoms other than those of the skin. Cases have been reported 
among Italian sailors coming to New York who eat polenta of their own 
making. 

Prognosis ought to be good for mild cases seen early, and for whom proper 
therapeutic measures could be employed. 

Treatment. — This would seem to be prophylactic as regards the case of 
grain, and dietetical, hygienic and climatic. Massage, galvanism, alcoholic and 
saline embrocations might benefit the systemic conditions. 

Arg. nit., Am., Arsen., Bovista and Phos. may be symptomatically indi- 
cated. 

ACRODYNIA 

(Dengue fever; Epidermic erythema.) 

This is an acute infectious disease, associated with articular and muscular 
pains and with lesions of the skin similar to the exanthemata, and occurring 
in certain localities, especially along the coast line of the warm countries of 
Europe, America, Asia and Africa, also in the Philippine and Sandwich 
islands. The disease comes on with premonitory anorexia, vomiting, diarrhoea, 
often oedema of the face, hands and feet, disturbances of sensation, such as 
darting pains, formication, numbness, burning heat, etc., and sometimes motor 
derangements, such as spasms and cramps of the muscles. The eruption comes 
out usually upon the hands and feet, occasionally extending over the limbs to 
the trunk. It consists of erythema in places resembling chilblain, and some- 
times papules, pustules and blebs intermingled with the redness, while on the 
other parts the skin becomes stained a brownish or blackish hue. Purpuric 
and gangrenous spots have also been observed. The thickened epidermis is 
thrown off in large scales, and the disease ends generally in recovery in from 
two to four weeks. Occasionally relapses may prolong an attack into months. 
It may be fatal in the weakly or aged. 

Etiology.- — Acrod3mia is contagious, and probably belongs among the ex- 
anthemata; it is relatively rapid in its spread, is usually transmitted by 
means of ships or travelers, and attendants and physicians have been infected. 
High atmospheric temperatures favor its development, and soil and clothing 
are considered to be the media of transmission. 

Pathology. — Meningitis and sero-purulent infiltration of the pia mater 
have been noted. The spinal nerve centres may be affected by the toxic ele- 
ment and present the primary morbid manifestations. 

Diagnosis and Prognosis. — All cases may be expected to recover un- 
less occurring in the very young or old or debilitated subjects. The mus- 
cular and articular features, both during and after an attack, and the peculiar 
eruption must be relied upon to diagnose this disease from the exanthe- 
mata. 



HYDRO A -•"-'■ , 

TREATMENT. — The general methods used in the care of the eruptive fevers 
are the best, such as light or liquid diet, rest in bed, warm alkaline baths and 
the indicated remedy. The same class of remedies mentioned under pellagra 
may suffice. 

HYDROA 

This term has deservedly fallen into disuse, and is almost entirely ignored 
by the German school. Although Crocker speaks of it as "revived by Bazin 
for certain groups of bullous eruptions which, in their clinical aspects, stand 
midway between erythema multiforme and pemphigus," and apparently places 
hydroa herpetiformis (dermatitis herpetiformis) in this group, there is very 
little in the descriptive literature of these affections to show why they should 
not all be assigned to erythema multiforme, dermatitis herpetiformis or possi- 
bly pemphigus. Even Bazin, who made three varieties, hydroa vesiculeux, 
hydroa bulleux and hydroa vacciniforme, subsequently admitted that the first 
is a form of erythema or herpes iris, while it is generally recognized that hydroa 
bulleux is a variation of dermatitis herpetiformis, and it is not improbable that 
the third may be also an extreme variation of that polymorphous disease, or of 
multiform erythema. This form, hydroa vacciniforme, is now considered to 
be identical with hydroa puerorum of Unna, and the recurrent summer erup- 
tion of Hutchinson, or hydroa vacciniforme seu astivale of Crocker. Only 
a few cases of this affection have been observed. Its chief characteristics are 
its occurrence and recurrence in summer, almost exclusively attacking young 
boys, and ceasing spontaneously as manhood is approached. The eruption 
occurs chiefly on the exposed parts of the skin, is symmetrical, and seems to be 
brought on usualty by exposures to the sun, cold, winds and artificial heat or 
cold. It consists of erythematous spots on which arise small or large vesicles, 
singly or grouped ; these become umbilicated, dry up, and when the crust falls 
off leave depressed scars. Sometimes the process is arrested and scarring does 
not take place. Burning sensations may precede the eruption and slight itching 
attend it. An attack may run its course in two or three weeks, or fresh crops 
may prolong its duration. The etiology is only indicated by its occurrence in 
boyhood, and from exposures to heat and cold. Vaso-motor disturbances are 
probable factors. 

Pathology. — The morbid process commences as an inflammation of the 
epidermis and corium, followed by the formation of vesicles in the epidermis 
and finally by necrosis. 

Diagnosis and Prognosis. — Diagnosis must be made from dermatitis 
venenata, erythematous lupus, pemphigus, erythema multiforme and derma- 
titis herpetiformis. The age of the patient, exposed locations of the vesico- 
blebs, and recurrence imder certain conditions during the period of youth, are 
diagnostic. Prognosis is uncertain until adult years are reached. 

Treatment is along the same lines as considered for the exudative 



260 POMPHOLYX 

erythemas. For a list of possible remedies, see those under erythema multi- 
forme. 

POMPHOLYX 

( Cheiro-pompholyx; Dysidrosis.) 

Definition. — An acute vesicular and bullous eruption, usually limited 
to the hands and feet, and nearly always symmetrical in distribution. 

Symptoms. — The eruption always appears upon the hands, most often 
between the fingers and upon the palmar surface, rarely upon the dorsal sur- 
face. The feet are seldom affected as much as the hands, and may escape 
altogether. There may be sensations of burning and itching shortly before 
the lesions appear. These consist of small, deep-seated vesicles, which show 
through the epidermal layers, resembling boiled sago grains in appearance. 
They"show a tendency to group, often around the orifices of the sweat duct, 
and as they appear more distinctly on the surface, may run together and form 
large, flatfish bulla 3 , filled with a clear fluid. The contents of the vesicles or 
bulla? gradually become opaque and finally purulent, dry up in the course of 
a week, leaving their epidermal covering to be exfoliated and the newly formed 
skin beneath red, dry and tender. The itching or burning sensations usually 
subside with the full distention of the lesions, which, however, show no 
tendency to spontaneous rupture, but may be broken by scratching or other 
traumatism. The disease tends to recur, and in rare cases may be almost 
continuous for a long time. Exceptionally severe cases may affect the whole 
palmar and other portions of the hand, and corresponding parts of the feet. 
In other cases the attacks may be so light as to be hardly noticeable and quickly 
subside. The disorder occurs most frequently in individuals who habitually 
perspire freely, and it was thought by Tilbury Fox to be due to sweat retention 
or a true dysidrosis. 

Etiology and Pathology. — The disease may occur in either sex, but is 
most frequent in women, especially in young, neurotic women, who have been 
subject to some nervous strain or worry. In those predisposed, mental emo- 
tions may precipitate an attack. Changes of temperature may act as an 
exciting cause, especially heat. Hence the disorder is more common in spring 
and summer, and may be brought on by exposure of the hands to artificial 
heat at all seasons in those subject to attacks. Organic and functional car- 
diac disease maj r act as a cause. Pathologically, this disease is probably a 
vasomotor neurosis, with vesicle formation in the rete ; the vesicles being at 
times directly connected with the sweat ducts, while in other instances no 
connection is apparent. Unna believes that a micro-organism similar to the 
tubercle bacillus is the pathological agent. 

Diagnosis. — The limitation of pompholyx vesicles to the hands and feet, 
without any tendency to rupture and produce a continuous discharge, but to 
dry up with or without first forming bulla?, and perhaps to recur repeatedly.. 




Fig. 72— POMPHOLYX 

Patient is a girl of seventeen, of a neurotic temperament and subject at times to 
sweating of feet and hands. Disease has appeared for three consecutive summers, 
the first and second attacks persisting about two months; the third attack began 
ten days ago. The onset was attended with burning sensations on the soles and 
sides of both feet, followed by the appearance of irregular groups of deep-seated 
vesicles, averaging the size of a small pea; these coalesced about the third day and 
formed large, variously shaped bullae with clear contents, which later became opaque 
and in a few days collapsed from absorption of fluid exudate. On the left sole may 
be seen the ragged fringe of the roof walls of these bullous lesions; on the end of the 
second toe a small collapsed blister; on the outer and fore part of the sole a large 
bulla at the acme of development, while on the outer side of the foot there exist 
some new vesicles still accompanied with burning sensations. At all stages the 
lesions are very sensitive to friction or pressure. Cured with bufo, sixth decimal. 
Xatrum sulph., sixth decimal, was later prescribed to prevent the annual recurrence. 




Fig. 73— POMPHOLYX 

Patient, a boy of eleven, who gave a history 
of two previous attacks. Cured with bufo, third 
decimal. 




Fig. 74.— PEMPHIGUS 

VULGARIS, OR COMMON, GENERALIZED VARIETY 

Patient is a young colored girl. Attack is attended with smarting, sticking and raw sensations, 
worse from warmth and touch, better from cold applications. Lesions consist of various sized blebs, 
most numerous on the legs, where many are in process of involution. Cured with cantharis, third. 
(Courtesy of Dr. W. T. Smiser.) 



PEMPHIG1 8 361 

arc characteristic points of difference from other vesicular d Neurotic 

eczema may show the same sago-like vesicles, bu1 they rupture spontaneously 
and leave a weeping Burface behind. Moreover the eczema vesicles are more 

apt to appear on the baek and sides of the fingers than on the palmar BUrJ 
If bullae form they can be distinguished from similar lesions of pemphigus 
by their formation from the coalescence of small vesicles. 

PROGNOSIS. — An individual attack Is usually over in ten to twenty days, 
but recurrences are not uncommon after an indefinite interval. 

Treatment. — The affected parts can be made more comfortable by appli- 
cations of simple ointments and thorough wrapping with a bandage. The 
curative treatment is by the internal remedy which, rightly chosen, nearly 
always cuts short the attack and tends to prevent a recurrence. Souro 
nervous depression should be combated, other disorders treated and means 
to improve nutrition instituted. Among remedies see indications for Bufo., 
Hepar, Nat. sul., Plios. arid. Ranunc. bulb. 



PEMPHIGUS 

Definition. — A chronic cutaneous disease characterized by an eruption 
of variously sized bullae in successive crops, usually without antecedent 
lesions and pursuing an indefinite course. 

Pemphigus as a distinct entity is a rare affection. Formerly the name 
given to numerous associated or secondary bullous eruptions occurring in the 
course of other skin diseases; some of the older writers making many vari 
notably B. H. Martins who succeeded in naming ninety-seven. The wholesale 
weeding out of pemphigoid eruptions has left a clearer but by no means typical 
disease, and some authorities with Kaposi still ignore the exclusion of some 
forms of bullous lesions now included by most writers with dermatitis herpeti- 
formis. Pemphigus, as regarded to-day by the majority of authors, is divided 
into two general types, pemphigus vulgaris and pemphigus foliaceus, with 
pemphigus vegetans, pemphigus acutus and pemphigus neonatorum as sub- 
ordinate varieties. 

Pemphigus vulgaris (Chronic pemphigus). — This represents the common 
form of the disease. There are usually prodromal febrile Bymptoms, which 
may be remittent, intermittent or continuous, with exacerbations at the onset 
of a fresh crop of the lesions. Anorexia, vomiting, functional disturbance of 
the heart and lungs are frequent also. During the course of a severe or pro- 
longed attack there may be alarming prostration presaging a fatal issue. The 
eruption may appear on almost any part of the body, bul is usually most often 
seen or abundant on the extremities: at first bilateral, often symmetrical, it 
tends later to irregularity in distribution (pemphigus disseminatus), and some- 
times to arrangement in groups. Tt appears in round or oval bullae, filled tense 
with a translucent fluid, varying in size from a pea to a hen's egg OT larger, 



262 TEMPHIGUS 

surrounded at first by the unchanged skin; it sometimes later shows a narrow 
encircling band of redness. The number of lesions varies from two or three, 
rarely only one (pemphigus solitarius), up to a hundred or more. They appear 
in crops at intervals of one or more days, each individual crop pursuing a fairly 
uniform course ; they may remain stationary in size and shape, or enlarge and 
sometimes coalesce ; their contents are at first serous, rarely bloody {pemphigus 
hemorrhagicus) , and later purulent, with corresponding changes in color. 
Whether ruptured or not they gradually dry up and form with their roof wall 
brownish crusts, which in a few days fall off, leaving uncovered a new epidermis 
of a reddish or purplish color, and sometimes terminating in brownish pig- 
mentations of a few weeks' duration. The length of a whole attack may vary- 
widely from six weeks to as many months. It shows a tendency to subside by a 
less and less number of lesions appearing, or by longer intervals between the 
crops until they cease to develop altogether. The future is uncertain; most 
often the disease recurs after a rest of a few months or longer, but it may not 
return at all. On the other hand, the attacks may recur with great frequency 
to end favorably later, or persist to a fatal termination. Locally the sensations 
may be slight, or moderately severe burning, itching and painful tension may 
be felt ; these may be increased from accidental rupture and excoriation of the 
lesions, or by the numerous lesions and consequent crusts. 

Extreme variations from the ordinary clinical type of chronic pemphigus 
may be more or less distinct, often less. Occasionally only the mildest general 
symptoms with a few lesions and short duration are seen, representing one ex- 
treme or pemphigus benignus. More frequently the variations are intermediate 
and less distinct between the benign form and the severe persistent type at- 
tended with prostrating pyrexia, cachexia and sometimes membranous growths 
(pemphigus diphthericus) found in or about the lesions; or infiltration, slough- 
ing (pemphigus gangrenosus) , or again ulceration of the superficial layers of 
the skin, representing the other extreme, or pemphigus malignus. Even the 
most benign forms of pemphigus ma} r , without apparent cause, take on ma- 
lignant phases and sometimes run a rapid and fatal course. Again, pemphigus 
vulgaris may merge gradually into the distinctively grave form known and 
described as pemphigus foliaceus. Following resolution of the bullae, milia 
sometimes form on their sites and are shed in the usual way after persisting for 
several months. In many forms of the disease, the mucous membrane of the 
mouth, throat, nose or eyes may be attacked, and one or more cases have been 
reported as occurring on the mucous surfaces without involving the skin. In 
one grave variety the attack nearly always begins in the mouth or throat. This 
form is also characterized by the development of peculiar vegetations in the 
cutaneous lesions, and hence was named by Neumann, pemphigus vegetans, and 
is now described by some writers as a definite form of the disease. 

Pemphigus vegetans is rare, and only about fifty cases have been recorded 
as occurring in America. With the onset of an attack there are general feelings 
of languor, malaise,' etc., followed in nearly every case so far reported by symp- 
toms of sore throat or sore mouth, pain on eating and swallowing being first 



PEMPHIGUS 



268 



noticed as surface signs of the disease. In these cases on the mucous membrane 
may be found ill-developed bullae, or their loosened membranous wall, which 
becomes later detached, leaving denuded, excoriated and exquisitely tender 
patches of equal size. After a variable interval of a few days or weeks ordinary 
pemphigus lesions appear about the vulva or on the hands, feet, groins, axillae 
and other parts of the surface, but show no tendency to become universal. Here 
the semblance to the common form of the disease on the skin ceases. Instead 
of drying up, the lesions become excoriated, ulcerate and sometimes spread by 
concentric peripheral growth, the primary lesion perhaps crusting over while 
new blebs form about it; while in certain regions as the genito-crural, axillary, 
anal or about the mouth and nose there arise more or less fungoid, papillary or 
wart-like growths, accompanied with a sticky, offensive secretion. These may 
enlarge into extensive patches and resemble condylomata. Some patches may 
heal, but new crops continue to appear and lead, as a rule, to more and more 
surface involvement, which, together with the painful state of the mouth and 
throat interfering with nutrition, rapidly exhausts the strength, and death 
occurs within a few weeks or months from asthenia or some intercurrent disease. 
Sometimes periods of improvement may alternate with aggravations for a 
longer time. The milder cases, including a few which followed vaccination, re- 
covered. 

Pemphigus acutus as a distinct variety has been denied by some, beginning 
with the older Hebra, who claimed that such reported cases were instances of 
mistaken diagnosis. The number of cases reported by competent observers 
would seem to refute this, though the type must be extremely rare in adults and 
uncommon in children if we eliminate the doubtful cases in which the bullous 
lesions were probably accidental features of erythema and the eruptive features. 
These attacks last from one to six weeks, and are usually preceded by febrile 
disturbance one or two days and attended with fever throughout the eruptive 
stage. When the last bulla? dry up the fever abates. Sometimes the pyrexia 
begins with distinct chills and the temperature continues high and may run 
into a typhoid state, or become complicated with pulmonary, renal or other 
affections, constituting one of the so-called forms of pemphigus malignus and 
ending fatally. Among the seventeen cases reported by Pernet, the history of 
the majority points to an infective origin of the nature of animal poisons such 
as bites. Demme considered a diplococcus to be the etiological factor. II' this 
belief of the causal factors can be demonstrated beyond a doubt, it will be 
necessary to assign pemphigus aeutus to another group apart from pemphigus. 
When this type occurs in infancy, pemphigus neonatorum, the disease is liable 
to be mistaken for the bullous syphilide. It attacks infants usually who are 
exposed to unsanitary surroundings, and outbreaks in hospitals and other in- 
stitutions appear to be contagious or epidemic in nature. Local prevalence of 
attacks has been noted in some instances as limited to the practice of a cer- 
tain midwife, indicating its probable contagious origin. Generally there is 
antecedent fever, which remits with the first crop of bullae. Other crops follow 
in rapid succession without any special predilection, bul often leaving the 



264 PEMPHIGUS 

■ 
hands, feet and mucous outlets exempt. Most cases run a favorable course in 
two to four weeks, but even in apparently healthy and well-nourished children 
the attacks may assume a grave type, the blebs burst, and ulcers or gangrene 
follow. The latter cases are likely to prove fatal in a week or ten days. When 
the contagious form of infantile pemphigus prevails it is frequently communi- 
cated to adults, in whom it runs a milder course. There is no doubt that this 
form is due to infection from pus-cocci, and it is generally admitted that it is 
an infantile form of impetigo contagiosa. Practically, it is not a form of true 
pemphigus. The same may be said of a similar type which occurs in warm 
latitudes, pemphigus contagiosus tropicus. 

Pemphigoid eruptions formerly looked upon as variations of pemphigus 
vulgaris, such as pemphigus pruriginosus. in which the intense and persistent 
itching and resultant excoriations from scratching after a short time produce 
secondary changes which completely mask the initial lesions, are now generally 
classed with dermatitis herpetiformis; while another term, pemphigus hysteri- 
cus, probably given to the same clinical type, as well as the variations in ob- 
jective features designated as pemphigus circinatus and pemphigus serpigi- 
nosus, are properly included in the same category. 

Pemphigus foliaceus. — The distinct features of this form of pemphigus 
are so different that were it not sometimes consecutive to severe pemphigus vul- 
garis it might be looked upon as a separate disease. It may, however, show its 
peculiarities at the onset, and whichever way beginning is an exceedingly rare 
disorder. The lesions consist of flaccid bullae usually developed from the ap- 
parently normal skin. They may contain so little fluid as to be only slightly 
raised above the surrounding skin, or as an effect of gravitation this may settle 
at one side, similar to a partly filled blister. The contents of the blebs soon 
become turbid, then purulent and sometimes sanious. The individual bulla? 
soon rupture and the flaccid wall acquires a feeble adhesion to the centre of its 
base, while the periphery progressively separates, curls up, presenting a re- 
semblance to dead leaves ; hence the terms pemphigus foliaceus given to it by 
Cazenave. The denuded skin, left somewhat exposed between the partly de- 
tached covering of the original bulla?, and at first moistened with -offensive 
serum and sero-pus, does not dry up, but exudes like an eczema rubrum, con- 
tinually forming by desiccation thin crusts. Kew epidermis may re-form in 
spots for a time, but is soon rubbed off or separated by renewed exudation or 
transient bulla?*. At first the disease may involve only a small area of the skin, 
but it gradually and symmetrically spreads until in the course of months or 
years every part of the surface is affected, except bulla? may not form on the 
palms or soles. The skin of these parts, nevertheless, becomes thickened, dry 
and easily cracks, so that practically the disease may be said to be universal in 
distribution. The disease is attended with a sickening odor, which may per- 
vade the room. Sensations of tension and stiffness are felt from the desiccation 
constantly going on: burning, smarting and sometimes itching are also ex- 
perienced. The oral mucous membranes may be affected, and instead of heal- 
ing as in ordinary pemphigus, the blebs soon macerate and are transformed into 



PEMPHIGUS 366 

grayish membranous patches. These may shed their diphtheritic covering, be- 
come raw, glazed and reddish-brown; according to their location, mastication, 
deglutition, respiration or vocalization may be seriously impeded. The con- 
junctiva is rarely affected, but in such cases vision may be lost from atrophy 
and adhesions of the membrane to the eyeball. The nails become thinned, 
curved, furrowed and are sometimes thrown off; the hair gets brittle and falls 
out generally or in larger spots, leaving small tufts; the eyes may become 
«ctrophic, and furuncles and abscess add to the already deplorable condition of 
the sufferer. The bodily temperature may remain norma] throughout the 
•course of the disease, or in the advanced stages there may be a low type of fever 
which together with insomnia and gastric disorders result in extreme emacia- 
tion, great prostration, rendering the patient very vulnerable to intercurrent 
disease. The course of pemphigus foliaceus is however usually marked by 
remissions, sometimes pronounced enough to raise false hopes of recovery. 

Etiology and Pathology. — Little is positively known regarding the 
•causes of pemphigus. Lack of vital resistance is a predisposing condition, as 
shown by the attacks more often occurring in infancy, childhood and in per- 
sons debilitated from physical or nervo-mental disturbances. Rarely the pre- 
disposition may be hereditary. Kaposi mentions an instance where cases oc- 
curred in the same and lateral branches of a family, and Carl Blnmer is quoted 
by Zeisler as reporting bullous eruptions appearing in sixteen members of the 
same family. Slight local injuries seem sufficient to bring on an outbreak in 
these cases of existing predisposition. Even without any evidence of heredi- 
tary tendency injuries of the peripheral nerves, spina] cord or brain have been 
noted as causes of bullous eruptions. Similar lesions have occurred in ass 
ciation with organic disease of the cord, its membranes, the sympathetic and 
the peripheral cutaneous nerves. Hysteria and other functional disorders of the 
nervous system have been reported as probable causes. Thus without enu- 
merating the many different individual diseases of the nervous system which 
have been observed associated with pemphigus, it will be seen how impossible 
it is to determine any definite relationship ; but only, as Crocker has remarked, 
that "the evidence goes to show that bullous eruptions may occur in connection 
with and probably indirectly due to lesions of the nervous system situated any- 
where from the centre to the periphery of the sensory tract. though similar 
lesions are much more frequently found with no bullae." It is probable that 
most cases of pemphigus acutus and pemphigus neonatorum are of septic origin, 
and some possibly contagious. Pernet reported seventeen cases of acute pem- 
phigus in butchers and others who handled animals or dead portions of animals ; 
in seven of these there was a distinct history of injury to the hand, and six out 
of seven butchers affected by the disease died. He refers to the presence of a 
diplococcus in the lesions, as confirming the previous researches of Pern mo. 
Whiphouse and others. The uncertainty as to whether the bacteria were pri- 
mary or secondary to the development of the lesions lessens the significance 
of these investigations. Eppinger has stated as his conclusions that pemphigus 
was not a bacteriological disease, but probably due to toxic poisoning. Euture 



266 PEMPHIGUS 

investigations will probably demonstrate that true pemphigus is infectious, due 
to an auto-intoxication. 

Pathology. — A marked increase of the eosinophilous cells in both bullae 
and blood has been noted, as in dermatitis herpetiformis. Kecently it has been 
shown that these cells are found in artificially produced vesicles on sound skin ; 
so the theory that they acted as irritants to the nerve centres is no longer ten- 
able. The bullae are usually superficially situated between the rete and the 
coxneous layer, or in the upper part of the rete. Weidenfeld calls attention to 
"the enormous dilatation of the blood- and lymph-vessels always present, to- 
gether with the cellular infiltration of their walls, the oedema of the papillary 
layer of the cutis, the changes in the elastic tissue fibres, and the cedematous 
condition of the rete." 

Diagnosis. — Pemphigus is to be distinguished from other affections in 
which bullous lesions develop. This is usually easy in chronic pemphigus from 
the lesions arising in the apparently sound skin, or at most with slight redness, 
and by their coming in crops for a more or less protracted period. The rarer 
forms of the disease may at times present difficulties in the way of recognition. 
By recalling the diagnostic features of any form and comparing them with 
those of any suspected disease the doubt as to their nature will seldom be more 
than temporary. As a rule, the comparison need include only a few of the 
more prominent characteristics of other diseases, thus: 

Dermatitis herpetiformis bullae are usually associated with other lesions, 
papules, vesicles, pustules, erythema, etc., pursue a variable course and are ac- 
companied by distinct itching or burning. Syphilitic blebs are rare except in 
early infancy, and then show a marked preference for the palms and soles. 
The rare pemphigus vegetans has been mistaken for cutaneous syphilis, but the 
history of primary bullae, sites of preference, grave character and the failure of 
antisyphilitic treatment would exclude the latter. Bullae occurring in leprosy 
would be associated with anaesthesia or other signs of that disease. Varicella 
bullosa is easily recognized by its consecutive occurrence and acute course. The 
bullae of impetigo contagiosa are associated with pustular lesions; it is con- 
tagious and auto-infectious, but readily yields to treatment. The bullous lesions 
of erythema multiforme show evidences of other inflammatory lesions, and 
occur chiefly on the dorsal surfaces of the hands and feet. Urticaria wheals 
may develop into bullae, but the mode of evolution, presence of other wheals 
with stinging or itching sensations and their ephemeral course leave no doubt 
of their nature. The crusts or scales of generalized psoriasis, dermatitis ex- 
foliativa, lichen rubra, pityriasis rubra and eczema rubrum might possibly be 
confounded with advanced pemphigus foliaeeus ; but the history of the original 
or primary lesions and their subsequent changes, even if no flaccid bullae could 
be detected at the time, would usually serve to differentiate the latter from any 
one of the former. Lastly, it may be necessary in some cases to exclude bullous 
drug eruptions, which may be produced by full doses of the iodine or bromine 
salts and other medicinal substances. This can be done by inquiry as to the 
medicines used within the few preceding weeks. Malingerers, insane or emo- 



PEMPHIGUS 367 

tionally diseased persons sometimes artificially produce blisters by applica- 
tions of vesicants. The surroundings or circumstances will usually give some 
clue in such cases. 

Peognosis. — The prospect of cure for ordinary cases of pemphigus is reason- 
ably good. The possibility of the simple form merging into pemphigus vege- 
tans, which is usually fatal, should not be forgotten. The forecast must also 
be qualified as to the duration of an attack and the liability to relapse. In 
pemphigus vegetans the outlook is always bad, and the acute pemphigus of 
septic origin is largely fatal. Long duration of the chronic forms and advanced 
age are unfavorable conditions. 

Treatment. — ^Regulation of the diet and other physiological habits are 
important in every case of pemphigus to bring the patient into the best state of 
nutrition. These needs will vary with each individual case. Locally the objects 
to be attained are cleanliness and protection. In mild cases local methods other 
than cleanliness need not be insisted upon, as the internal treatment is usually 
effective. Even in the severer forms local measures may be largely governed 
by the degree of comfort they afford the patient. While the warm bath made 
mildly alkaline with borax, bicarbonate of soda, or aqua ammonia, saline with 
salt, or soothing with bran, is commonly useful and comforting, it does not 
always agree with patients. In such cases limited sponging of the surface 
where cleanliness is absolutely essential may be substituted. For aggravated 
or universal pemphigus the continuous hot-water bath as employed in hospitals 
in "Vienna, wherein the patient lives for weeks or months, is of great service. 
In whatever way measurable cleanliness is maintained, following it, protection 
should be given to the surface when needed. This may consist of simple dust- 
ing powders of starch or combined with oxide of zinc, compound oleate of zinc, 
etc., simple lotions of glycerine and rose water, or application of sweet almond, 
cotton seed, sweet or linseed oil. Sherwell has reported a case of pemphigus 
foliaceus cured with linseed oil employed both locally and internally. Some 
of these can be used at the same time (when suitable) as vehicles for mild 
antiseptics when called for by the local conditions, such as two to five per cent, 
of boric acid, one per cent, of subnitrate of bismuth, one to two per cent, of 
carbolic acid or one-tenth of one per cent, of thymol. I have found an aqueous 
solution (one to five hundred) of permanganate of potash, the same as em- 
ployed in eczema, a comforting local application. In fact, almost any applica- 
tion adapted to eczema may be useful in severe pemphigus. After all, the 
primary objects of local measures are to be kept in view, for they have no cura- 
tive action. For the latter purpose we must look to internal medication. 

Arsenicum, rhus and phosphorus are most often indicated for internal ad- 
ministration. See also Bufo, Colch., Copaiva. Dulc.. Kali hrom.. K. iod.. Loch., 
Nat. sulph,, Secale, Thuja, 



268 SCLERODERMA— DIFFUSED SYMMETRICAL SCLERODERMA 



SCLERODERMA 

(Sclerodermia; Sclerema adultorum; Scleriasis; Dermato-sclerosis; Hide- 
bound disease, etc.) 

Definition. — A cutaneous affection, characterized by circumscribed or 
diffused induration and increased fixation of the parts involved. 

The first case of scleroderma recorded was in Italy in 1752, and is referred 
to by Willan as ichthyosis cornea. Since then it has been described under vari- 
ous' names, some of which are given above. It occurs in two principal forms, 
anatomically the same, but different in distribution and extent, and sometimes 
existing together. These are (1) diffused symmetrical scleroderma; (2) cir- 
cumscribed scleroderma, often termed morphcea. 



DIFFUSED SYMMETRICAL SCLERODERMA 

Symptoms. — This is a rare affection, but from its distinct features is now 
well known. It begins most frequently after exposure to cold and wet, with 
rheumatoid pains or stiffness in the limbs or joints. This onset may be very 
insidious and not clearly remembered by the patient, or the changes in the 
skin may be the first symptoms observed and seem to appear in a comparatively 
short time. The first noticeable change in the skin is in infiltration without 
any signs of inflammation or rise of temperature, and with or without oedema. 
In the former case the surface may pit on hard pressure, but owing to the 
density and stiffness of the parts there is none of the doughy feel of ordinary 
oedema ; more often oedema is absent and the volume of the skin is not markedly 
increased. In a variable period of time the skin becomes symmetrically and 
progressively hard and rigid. Universal scleroderma is, however, relatively in- 
frequent, and the palms and soles are then usually exempt. It may be said to 
always attack the upper segment of the body, sometimes the lower simultane- 
ously, but never the legs without the arms being also involved. The common 
sites of preference are the anterior and posterior surfaces of the chest, the 
shoulders, upper arms, forearms, back of hands and finger-joints, back of neck, 
face and scalp, legs and thighs. On the chests in women it may cause a dis- 
appearance of the breasts and more or less impede respiration; on the face it 
restricts the movements of the mouth, eyelids and other motions of the facial 
muscles, giving to the countenance a distinct lack of expression. The eye- 
lids, which often escape, may be contracted or everted according to the part 
most affected. The affected skin merges imperceptibly into the sound, though 
usually within an inch or two from the border of the indurated portion the 
surface may be found entirely normal. At the height of the diseased process 
the affected cutaneous tissues have a leathery hardness and rigidity which can- 
not be impressed with the finger or pinched into folds, but if the finger is 
drawn across it with hard pressure a whitish line is left into which the color 



DIFFUSED SYMMETRICAL SCLERODERMA 269 

slowly returns. Sometimes on hasty inspection the surface may look lilt I. 
changed, but on careful examination the normal lines will be found largely 
obliterated. Occasionally the parts may have a frozen appearance without cold- 
ness, while the surface temperature is normal or only one or two degrees below. 
Sensibility is usually unimpaired or only slightly increased or diminished, 
though frequently there is pain on pressure, and itching is easily excited in some 
cases. Otherwise the skin may be little disturbed in its functions or normal 
reactions to accidental irritations; or again the surface may undergo various 
modifications in different cases, or at different times in the same case. Dilated 
capillaries in tufts or stria? may appear in contrast with the abnormally pale 
surface, light brown to blackish pigmentations are not infrequent in lines, spots 
or diffused over a large area ; loss of pigment may occur in circumscribed patches 
of various shapes and sizes with a waxy, glistening surface resembling marble; 
superficial or deeper nodular-like swellings may arise and after a time disappear 
spontaneously; crusting of the affected surface may occur in places. One of 
my patients had at different times thick crusts form, made up of several supra- 
imposed layers of yellowish scales; they were always situated over the tibia, 
and their development was preceded and accompanied by itching, but without 
the ordinary signs of inflammation. The mucous surfaces of the tongue, gums, 
palate, pharynx, larjmx and vagina may be affected by the disease, and be 
manifest in spots or bands of sclerosed membrane. 

The disease may pursue an erratic but symmetrical course, changing its 
situation or progressively extending, and with periods of aggravation and occa- 
sional amelioration lasting for years. When it has reached its maximum evolu- 
tion, or is arrested by treatment, restoration or involution may follow and the 
skin regain its elasticity, mobility and functions. Failing in this atrophy be- 
gins, the parts involved become reduced in size by compression and absorption 
of the fat in the subcutaneous tissue and thinning of the other layers of the 
skin. Even the muscles may disappear under the pressure, and the atrophic 
skin seem attached directly to the bone beneath. In different regions the 
atrophic stage produces different effects. The limbs of an adult or portions of 
them may be shrunken to the size of a small child; the joints appear enlarged 
and pseudo-anchylosed from the tensely constricting skin. Ulceration or gan- 
grene may follow from slight injuries. Sometimes the bones become thinned 
or necrosed, the fingers stiff and distorted, and the hand inflexible at the wrist. 
On the face the lips may be shortened, the nostrils compressed, the skin drawn 
tightly over the bones, the teeth fall out from constriction of the gums, and 
rarely the eyelids are fixed, open or retracted, exposing the globe of the eyes. 
When the atrophic stage is well advanced, restoration to a healthy condition of 
the skin never occurs. The contracting process may be arrested by judicious 
treatment, but the extreme sclerosis is not replaced by normal tissue and de- 
formities remain unrelieved. The general health and bodily functions may 
remain unaffected for a long time, but gradually nutrition fails and the patient 
finally sinks under emaciation, insomnia, neuralgic or rheumatic pains, mental 
depression, etc., into a fatal marasmus or exhaustion ; more frequently some 



270 



DIFFUSED SYMMETRICAL SCLERODERMA 



complication of the lungs, heart, kidneys supervene and hasten the end of a 
hopeless state of being. 

The duration of the disease is long but uncertain. Kaposi mentions a case 
of Strassmann's which had persisted for thirty-one years without loss of gen- 
eral health. In children the onset, course and termination are usually more 
acute, and the tendency to atrophic changes less marked or persistent. Suf- 
ferers from the disease are generally very sensitive to atmospheric changes, 
especially to cold and wet. 

Etiology and Pathology. — At present there is no plausible etiological 
basis known for scleroderma. Three out of four cases occur in females, which 
may, perhaps, indicate the neurotic nature of the disease, as does also its more 
common origin in middle life, when the nervous system is usually subject to 
the greatest strain, but the disorder may arise at any age; thirteen months 
and seventy-two years are the extremes of age in recorded cases according to 
Crocker. Among numerous inferential causes mentioned by authors are priva- 
tions, exposures to cold or heat, rheumatism, erysipelas, traumatisms, mental 
emotions and diseases of the viscera. -Most cases do not show a dependence on 
any direct cause, and in many the previous health has been good up to the be- 
ginning of scleroderma. My own cases have with one exception had associated 
rheumatic pains, but these do not seem to have antedated the beginning of the 
infiltration of the dermal tissues. The real nature of the pathological process 
is unknown, but the cause is probably neurotic from some obscure disorder of 
the nerve centres acting on the trophic nerves of the skin, producing connective 
and muscle tissue hypertrophy, with consequent obstructive compression of the 
arterial, venous and (probably) rymphatic vessels, compression of the glands 
and fat lobules and a disappearance of the contents of the latter. In the second 
stage, of the disease atrophic changes may take place in all the anatomical parts 
of the skin and the tissues directly beneath. 

Diagnosis. — The firm, hard, non-elastic, corpselike appearance of the skin 
with symmetry of involvement and without signs of inflammation will always 
remind one of scleroderma. Only one other disease closely resembles it, 
sclerema neonatorum, and this always begins in early infancy, months before 
the youngest known case of scleroderma originated. Moreover, in sclerema of 
the new born the surface is always cold. The rare affection known as angioma 
pigmentosum et atrophicum may be distinguished by its chief occurrence on 
the exposed portions of the body and its tumor-like growths. 

Prognosis. — Some cases of scleroderma tend to recover spontaneously, 
owing probably to the early abolition of the underlying neurosis. There may 
always be held out a hope of recovery before the advent of the atrophic stage, 
and this the more, the shorter the duration of a case. Even after moderate 
atrophic changes recovery may ensue in a slow or irregular way. No prediction 
can be made with any certainty as to time of restoration in any case. In the 
extreme atrophic state the prognosis is unfavorable as to recovery or long life. 

Treatment. — Therapeutic efforts should be directed to a restoration of 
the equilibrium of the nerve functions which preside over the nutrition of the 




CIRCUMSCRIBED si LERODERMA 271 

in by attention to the general hygiene of the individual and his or her en- 
vironment. The diet should be plain but nutritious, the clothing warm and 
protective against alternations of temperature, the skin kept active and mod- 
erately stimulated with salt-water baths, or frictions with alcohol, hay ruin, or 
simple oils or fats. The more nutrient oils like cod-liver, sweet oil, lanolin 
diluted with the latter, or sweet almond oil may be of additional advantage, 
especially when combined with general massage of the affected skin. The Turk- 
ish bath may replace other modes of bathing for those who can employ it, fol- 
lowed by inunctions of simple oil or fat. Sources of aggravation, such as cold 
and wet, should be avoided, and when practicable change to a mild, equable 
climate near the sea is advisable. The high frequency currents or galvanism 
over the spine may be beneficial. Of most importance is the selection of an 
internal remedy. If rightly chosen, there will be almost invariably some re- 
sponse to its administration. Pathologically and symptomatically rhus tox. 
will probably be most often indicated. See also Arsen., Bnj., Cannab. ind., 
Graph., Hydrocot., Opium. 



CIRCUMSCRIBED SCLERODERMA 

(Morphcea; Addison's keloid.) 

Although clinically different and once believed to be a distinct disease from 
diffused scleroderma and termed morphcea, the latter is now generally recog- 
nized, at least anatomically, as a circumscribed variety of the former. 

Symptoms. — The lesions of this variety may appear without any general or 
local subjective sensations, and if situated on unobserved parts of the body may 
not attract the attention of the patient until accidentally seen. It is of rather 
more common occurrence than the diffused form, but still a comparatively rare 
affection. In shape the lesions may tend to show in patches, bands or in varia- 
tions or combinations of these, the patch-like outline being the more common. 
In size they may vary from a small pea to three or four inches in diameter or 
even larger, and may be single or multiple. The color may vary from the dull 
white of an old cicatrix to a yellowish-white which has been likened to old 
ivory, commonly bordered by a narrow line consisting of aggregations of minute 
blood-vessels which may give to it a pinkish, violet or lilac tinge of color, and 
occasionally the dilated vessels run irregularly on to the body of the patch. 
The patches generally occur on one side, most often on the leg, arm, the trunk 
(especially on the breast), neck, head and face, particularly in the region sup- 
plied by the fifth nerve. Sometimes the distribution is like that of zoster along 
the line of the cutaneous nerves. To touch, the affected skin may feel like 
parchment or more like firm leather, according to its thickness, the ease with 
which it can be pinched up into folds, whether it is level with or slightly raised 
above the surrounding surface. These qualities may vary in different patches 
or even in the same patch. As the lesions develop the surface usually becomes 
smooth from obliteration of the normal lines and absence of hairs, dry. some- 



272 CIRCUMSCRIBED SCLERODERMA 

times fissured and occasionally contracted into folds radiating toward the 
centre. They may remain unchanged for a long time, or new pearly-white 
atropine points may continue to appear in the adjoining skin, enlarge, thicken 
and finally coalesce with the older patch. Other odd forms may occur in the 
neighborhood of circumscribed patches in the shape of straight or curved 
bands, streaks or ribbons. These may, however, be primary and characterize 
the attack. The linear lesions are more apt to be attached to the subcutaneous 
tissues, and hence may be sunken below the level of the surface and present a 
corresponding groove and ridge side by side. If not adherent to the parts 
beneath they may be elevated above the surface. On the limbs the bands may 
extend with the axis of an extremity for a considerable portion or even the 
whole length. On some parts of the face band-like formations are not ex- 
tremely rare, and when terminating at the median line of the forehead the 
resemblance to a cicatrix or keloidal growth may be very apparent. Vari- 
ations an the features of typical morphcea may be seen in almost any direc- 
tion. The centre of a patch instead of being white may be more or less pig- 
mented in shades of yellow, brown, green or black. The vascular border may 
be absent in some cases, and in others the main portion of the lesion may 
be hypergemic. Patches may develop quickly and pass through a rapid evolu- 
tion; the more atrophic lesions may become adherent to the parts beneath 
as in the diffused form, and wasting of muscles may occur primarily or in 
turn, bringing the skin directly on to the periosteum in some cases; even 
exostosis has been noted and occasionally ulceration of the patches. There 
may be an absence of perspiration in the affected skin, without loss of sensi- 
bility or disturbance of sensation beyond moderate itching and burning, in' 
some cases. 

The duration of the disease may vary from one to ten years, and in its 
course may remain stationary when fully developed for a long time, or new 
lesions may continue to appear while others involute and leave no trace behind. 
It very rarely involves a large extent of the surface at any one time or more 
than one region. Seldom are the onset and course both acute, or the other 
extreme of chronicity reached. Neither is the general health apparently dis- 
turbed, though the disease with exceptional rarity may run a rapid course, 
and in later association with tuberculosis or some other constitutional or vis- 
ceral affection prove fatal. 

Etiology and Pathology. — This disorder is more common in young 
adults and children, but may occur at any age. The neurotic temperament 
appears to be a predisposing factor, and nervous strain in the way of anxiety, 
worry or depressing surroundings contributing influences. Among excit- 
ing causes have been mentioned alternations of temperature, such as occur 
in variable climates, local frictions from collars, garters, traumatisms, irrita- 
tions from medicinal applications, etc. After all, little is known about the 
positive causes outside of the implication of the nerve supply of the affected 
area resulting in defective innervation. The pathological process thereby in- 
duced seems to be a cell exudation around the vessels, narrowing their calibre 



LEUCODERMA ^~-> 

and proportionately diminishing the current of blood, sometimes leading to 
thrombosis or rupture and effusion. The morbid process may involve all or 
only a portion of the vessels of a part; when the blood supply is entirely 
cut off an atrophic lesion results, while from incomplete loss of circulation 
partial atrophy associated with increase of connective tissue results in a hyper- 
trophic lesion. The consequent increase of blood pressure in the collateral 
capillaries at the periphery of the anaemic spot causes their dilatation and the 
resulting border of color before noted. 

Diagnosis. — The recognition of circumscribed scleroderma is rarely at- 
tended with any difficulty. The smooth, ivory-white patch with a narrow tinted 
border and situated on one side are distinctive of the ordinary type. Morphcea 
may be occasionally symmetrical, but it is always circumscribed as compared 
with diffused scleroderma. Leucoderma or vitiligo is an atrophy of pigment 
only, unattended with any change in the texture of the skin, unlike morphcea, 
and moreover the color is a dead white rather than the yellowish or ivory 
white of the latter. Keloid and the more hypertrophic band forms of circum- 
scribed scleroderma have a resemblance, but keloid is denser, more vascular 
and elevated than the former, and frequently will show the claw-like prolonga- 
tions into the sound skin at its more distant extremity. Whether some or all 
of the unilateral forms of atrophy of the skin supplied by the fifth nerve are 
identical with morphcea or not is undetermined and not important, as etio- 
logically they are due to similar effects of innervation. Finally it may be 
remembered that cases of mixed scleroderma have been recorded, and though 
few in number, they serve to show the clinical as well as the pathological iinity 
of the diffused and circumscribed forms. Either form may be primary in 
order of occurrence. In the single mixed case seen by myself the diffused type 
developed first and was followed in a few months by patches of morphcea. 

Prognosis. — This is good in the majority of cases for ultimate recovery, 
but the duration under treatment is uncertain. Some cases recover a normal 
condition of the skin in a few months, others may last for years. Crocker 
states that patched cases are more favorable than band cases. 

Treatment. — This is practically based on the same principles as for the 
diffused form, modified according to the existing differences. The same general 
and individual hygiene and the same indicated remedies are the means to be 
relied upon to hasten involution. The Rontgen rays have been employed, but 
with indifferent success. 



LEUCODERMA 

Abnormally white skin may be a congenital defect, or it may be acquired 
as a direct result of atrophy of the normal coloring matter in the epidermis, 
which varies widely in different races and somewhat in different individuals 
of the same race. When absence of the pigment is congenital, it is known as 
leucoderma congenitalis, or albinism, and when acquired, it is called leucoderma 
acquisitum, or vitiligo. 



274 ALBINISM— VITILIGO 



ALBINISM 

(Albinismus; Congenital leucoderma; G. leukasmus; 0. leukopathia; C. 

achromia.) 

Definition. — A congenital absence of pigment in the skin and other 
tissues, universal or partial. 

Symptoms.- — A child born with complete absence of visible pigmentation 
is known as an albino. The hair, iris and choroid are affected as well as the 
skin. The latter may be perfectly white or pinkish in color owing to the 
differences in thickness and transparency; the hair is fine, soft and silky, 
white or yellowish-white in color, and in one case observed by Folker it was 
red. Absence of coloring matter in the iris and choroid permits the color of 
the blopd in these parts to show through, giving the former a pinkish tint, 
and the pupil a red appearance. In order to protect the abnormally exposed 
retina from excess of light the iris, eyeballs and lids are kept in a constant state 
of alternating motion when subject to ordinary rays. Albinos are usually 
congenitally weak, and grow up undersized and feeble physically and mentally ; 
there are, however, some exceptions to this rule. 

Partial albinism is much the most common, and like the universal form is 
more often seen in the dark races, especially in the negro at birth. The absence 
of pigment may occur in isolated, regular or irregular, roundish patches of a 
white or pinkish-white color, sharply defined by the normally pigmented surface 
or ill defined by a border of partially pigmented skin. This congenital defect 
is rarely seen in the white race, but the opposite congenital hypertrophy of 
pigment, the flat pigmentary mole, is not very rare in white people, and is 
alike persistent throughout life. Hairs growing from a patch of unpigmented 
skin are white. (Complete absence of pigment is not uncommon in animals 
and birds, as ferrets, rats, blackbirds, while partial albinism is very common 
among domestic and other fur-bearing animals.) Heredity is doubtless an 
important etiological factor. The condition is incurable. 



VITILIGO 

(Leucoderma acquisitum; Acquired leukasmus; Leukopathia; Achromia; Pie- 
bald skin.) 

Definition. — An acquired disorder in which the normal pigmentation 
of the skin progressively disappears from round or oval patches, leaving 
them white, smooth and sharply defined by a surrounding border of in- 
creased pigmentation. 

Symptoms. — This affection is said to be quite common in tropical countries, 
but is rarer in temperate and colder latitudes. It is purely a disorder of pig- 
mentation, the texture and functions of the affected skin remaining undis- 
turbed, and it is probable that it first begins with a moderate increase of pig- 




Fig. 75.— LEUCODERMA 

VITILIGO 

The subject is a colored man about sixty, who has suffered from periodic 
pruritus of the legs. Small white spots began to appear on the head and chest 
fifteen years ago, and some have slowly increased in size. Pruritus cured with 
sulphur, third decimal, without change in the anomaly of pigmentation. 




Fig. 76.— LEUCODERMA 

VITILIGO 

The patient is a middle-aged white woman who was subject to scrofula in 
childhood. Loss of color in circumscribed areas of the skin on the back of hands 
and wrists was first noticed eight years ago. Several patches on the dorsal surface 
of the hands have coalesced, and hypertrophy of pigment is quite pronounced at the 
border of this bleached area. The normal skin is fine in texture, thin and sensitive. 
Burning sensations are occasionally felt in the affected parts. Cured under the pro- 
longed use of silicea, sixth decimal, and infrequent local frictions with capsicum, 
second decimal. 



VITILIGO 276 

iihiit deposit, which in the majority of cases is only observed ;it the border after 
atrophy of pigment has occurred. This begins in small, milk-white, smooth, 
round or oval spots, which may enlarge symmetrically or irregularly to a less 
or greater degree. In colored people occasionally the absorption of pigment 
■goes on progressively from one or many points until nearly all the surface 
becomes white, leaving here and there an island of normal-hued skin. When 
the patches unite, very irregular outlines of bleached skin may be found. 
Hairs in the affected portions become white, but retain their vigor and firm 
implantation in the follicles; the secretions and sensibility of the spots are 
also unchanged. Their edges are always convex and correspond to the concave 
border of the over-pigmented surface. The contrast is most apparent in the 
summer, owing to the tanning of the colored parts from exposure to sunlight, 
and occasionally with the return of winter the disorder becomes permanently 
less conspicuous. The progress of the whitening process is always slow, con- 
suming years when it extends over large areas, and when more than half of 
the surface is involved in map-like distribution of white and dark shades of 
color, it may appear as though the latter were the abnormal portions of the 
skin. Rarely the loss of pigment may become universal and a spontaneous 
cure appear to be effected, but the normal pigment is not restored. The disease 
may start on any part of the surface, but is probably most often seen upon the 
back of the hands, neck, face, scalp and genito-crural regions; one spot may 
form at a time, and after an indefinite interval additional spots appear on 
other parts. The piebald look is intensified by the small size and the greater 
number of patches. The general health is unaffected directly by this disorder, 
though there may be associated disturbances of the nerve functions. 

Etiology astd Pathology. — ISfo actual cause of vitiligo is known. Heredi- 
tary tendency has been noted in so few instances as to be of little or no signifi- 
cance. It affects equally both sexes, and appears primarily most often in early 
and middle adult life, but is not limited to this period. It has followed after 
severe sickness in many instances, such as malarial and eruptive fevers; and 
has often occurred in association with neurotic forms of disease, such as mi- 
graine, alopecia areata, morphcea, Addison's disease, Graves' disease, etc. Some- 
times exposure to heat of the sun or to cold has seemed to stand in causal 
relation to attacks, and it has been observed to begin after injuries to the sur- 
face tissues. The various etiological factors have little in common except 
as they are induced by or lead to depression or derangement of the nervous 
system. Therein rests, together with the change in the skin (atrophy of pig- 
ment), about the only grounds for the assumption that vitiligo is pathologically 
a tropho-neurosis. Leloir and Chabins have reported atrophy of the sub- 
dermal nerves in areas of vitiligo. The deep rete cells of the affected areas 
lack the normal pigment granules, while those at the borders are abundantly 
supplied. 

Diagnosis. — The white patches of otherwise unchanged skin with a sur- 
rounding border of deepened pigmentation, usual symmetrical occurrence and 
history of development will always distinguish vitiligo from all other cutaneous 



276 ATROPHIA CUTIS 

affections. Macular leprosy in its later stages when the skin has become pale 
might be mistaken for vitiligo ; but unlike leprosy, the spots of vitiligo are not 
anaesthetic or structurally changed, and the general health is unaffected by the 
disease. When the loss of pigment has become general on certain parts or over 
the whole surface, the islands of color. might be confounded with chloasma. 
Here the usual convex outline of whitened skin would distinguish vitiligo from 
the concave line of lighter surface surrounding a patch of chloasma, and a 
comparative inspection of the surrounding skin would demonstrate its abnormal 
whiteness in a case of vitiligo. Morphcea can always be differentiated from 
vitiligo by the change of texture of the skin in a lesion of the former and its 
other features. 

Prognosis. — The tendency of this disorder is to persist and increase with 
age. Earely it ceases spontaneously and occasionally from treatment. 

Treatment. — Chief reliance is to be placed on the administration of an 
indicated drug and hygienic measures, if needed, to improve the general and 
local innervation. Frictions of the affected surface sufficient to produce a 
determination of blood to the part I have found beneficial in several cases. One 
of my patients with a pronounced form of the disease on the back of the hands 
and forearms regained the normal color in the whitened patches while using 
once daily the following local application : 

fy. Tr. cantharides 3 4. 

Tr. benzoin 3 1- 

Alcoholis, 

Aquse rosse aa § 2. M. 

Satisfactory as well as negative results have followed the use of hypodermic 
injections of pilocarpine, of the application of pure carbolic acid (Savill), of 
phototherapy (Montgomery), of the high frequency currents and of radio- 
therapy. The editor believes that the last method, that of the Wont gen or 
X-rays, is the most worthy of mention', and that radium in the quantity and 
quality now obtainable is absolutely worthless (from observation on six cases). 

The employment locally of corrosive sublimate, acids or caustic alkalies to 
remove the excess of pigment around the patches of vitiligo, and thus lessen 
the. disfiguring contrast of color, have been recommended, but are of doubtful 
utility. On exposed parts of the skin temporary relief from the disfigurement 
can be obtained by lightly staining the patches with walnut juice or some cos- 
metic preparation. Any indicated drug may be employed. Arsen., Sul., Nit. 
acid and Zinc pli os. have proved beneficial. 



ATROPHIA CUTIS 

Like other organs of the body, the skin may undergo atrophic changes, 
idiopathic or symptomatic in character, general or limited in extent, gradual or 
rapid in development. Often, atrophy of the skin follows other pathological 
relations, but it mav be coexistent with them. 



ATROPHIA SENILIS— ATROPHIA MACULOSA ET STRIATA 277 

ATROPHIA SENILIS 

(Senile atrophy of the shin; Atrophoderma senile.) 

The cutaneous degeneration peculiar to old age is macular, in its simplest 
form, pea- to bean-size and brown in color. These lesions are often found on 
the face, dorsum of the hands, genitalia and legs. Generally speaking, the skin 
may assume a dull brown or yellowish tint, become wrinkled and dry with 
slight scaling; the hairs atrophy and are of the lanugo-type; verruca of all 
types and sizes and telangiectases may appear. 

The pathological changes present in quantitative atrophy consist of a 
marked diminution of the fat-cells in all parts of the derma, a thinning of 
corium and epidermis, an increased pigmentation in the rete, a shortening of 
the hair follicles, dilatation of the glands and a disappearance of some blood- 
vessels while others become dilated. Degenerative atrophy may be fatty, amy- 
loid, vitreous, granular, etc.. in character. 

Prognosis and Treatment. — Having once been established senile atrophy 
is incurable, but protection from all harmful influences, and physiological liv- 
ing as regards both food and hygiene, will, if taken in time, often prevent 
or postpone its development. Massage, galvanism, the high frequency cur- 
rents, bran and salt baths, inunctions of plain oil, and wholesome food are ad- 
vised. All warty growths must be watched and protected, else they may become 
malignant in character. The indicated remedy in all cases is most important, 
and should be prescribed on the totality of symptoms. 

ATROPHIA MACULOSA ET STRIATA 

(Atrophoderma.) 

Partial atrophy of the skin results from the relaxation of the normal ten- 
sion following stretching or tearing of the elastic fibres of the derma. The 
released blood-vessels dilate for a time, producing a dull reddish or faint pur- 
plish discoloration in the affected area. Then follows atrophy with loss of the 
papillary layer of the corium and diminution of the number of the vessels and 
glandular appendages. The hair may be absent or scanty. - Such a condition 
may be idiopathic or symptomatic. It may occur from traumatism, as in the 
permanent marks left by a lash with a whip capable of injuring the elastic 
tissues beneath the intact epidermis ; or from distension of the skin by ascites, 
anasarca, pregnane}' (linear albicantes) , tumors, excessive deposits of fat, etc. 
Accompanied by fatty, lardaceous or waxy degeneration of the cutaneous ele- 
ments, partial atrophy is a sequel of syphilis, lepra, and many other diseases 
of the skin. From its usual occurrence in spots or lines this class of atrophy 
of the skin gains its title "maculosa et striata." The lesions are smooth, glisten- 
ing, scar-like, thin and depressed or grooved, with a peculiar mother-of-pearl 
lustre. The lines, an inch or more long and an eighth to one-quarter of an 



278 KRAUROSIS VULVAE— GLOSSY SKIN 

inch in breadth, are usually parallel with an oblique direction often following 
the natural lines of the skin. They may be nearly or quite on a line with the 
axis of the body on the trunk, but often at right angles on extremities. They 
are found over the distended part, or often on the hips, buttocks and thighs of 
adults, chiefly women. They may occur after severe sickness, such as typhoid 
fever. The macules are more rare,* and are isolated, round or oval, varying in 
size from a pin head to a finger nail. They bear a coarse resemblance to a 
vaccine cicatrix. All the lesions lack subjective sensations, and may be more 
or less anesthetic. Eare cases of the idiopathic forms are described, in which 
large macules are found about the ankles of women with menstrual derange- 
ments, the cicatriform condition following a brown pigmentation. In others 
there is a preliminary development of capillaries. A pigmented area some- 
times surrounds the atrophic patch. 

Etiology. — It is apparent from the description of this form of cutaneous 
atrophy-that it may be due in part to varying causes, which are obvious in the 
symptomatic types, but the idiopathic form at least can only be explained on 
the ground of its tropho-neurotic pathology, with malnutrition and circulatory 
disturbances as predisposing factors. 

Diagnosis. — The idiopathic form must be distinguished from the atrophic 
lesions that may be left by scleroderma, syphilis, etc. This can be done by 
careful investigation of the history of each case. 

Treatment. — See indications for Graphites, Opium and Sulphur. Pro- 
phylaxis is outlined under atrophia senilis. 



KRAUROSIS VULVAE 

Breisky, Heitzmann and others have reported a peculiar rare atrophic con- 
dition wherein the labia minora, preputium clitoridis and vestibulum shrink 
and become shriveled. In many instances, a congestive period with itching, 
burning and hyperesthesia precedes the atrophic state. Women of all ages 
have this condition irrespective of coitus or pregnancy. The etiology is ob- 
scure and the disease is chronic in its course. 

Treatment. — This should be directed towards removal of the cause, and 
a careful hunt will usually reveal some abnormality of the nervous system that 
needs treatment. Locally curetting and radiotherapy might be indicated in 
extreme instances, but the greatest dependence must be placed on the indicated 
drug plus the proper hygiene and diet. 



GLOSSY SKIN 

(Atrophodermia neuritica.) 

Glossy skin is a trophic disorder of the skin, seen especially in the "glossy 
fingers" described by the neurologists. One or more fingers become tapering, 
smooth, hairless, unwrinkled, glossy like a highly polished scar, and in color 
pink and ruddy, or blotched as with highly permanent chilblains. The nails 



PERFORATING ULCER OF THE FOOT 279 

curve mward. and the epidermis under the free edge is frequently thickened. 

Alter some time the nails drop off. The skin is delicate and easily inflamed, 
excoriated or fissured. There are associated severe burning pains and other 
abnormal local sensations. 

ETIOLOGY. — The condition results from local injury to the nerve trunk 
supplying the affected lingers, or from systemic disease causing neuritis in the 
same location. It is noticed in non-tubercular leprosy, gout and rheumatism. 
Impaired circulation is a predisposing cause, and exposure to severe cold may 
produce it. There is usually at some time in the course of the disease a si 
neuralgia. Most cases are tropho-neurotic in character. 

TREATMENT. — This should be directed towards the removal of any at 
ciated cause and the restoration of innervation. In the meantime the parts 
should be protected from cold and all irritations. Gentle massage and the high 
frequency currents may be used to advantage. 



PERFORATING ULCER OF THE FOOT 

(Malum perforans pedis.) 

This is a tropho-neurosis found usually on the foot, but occasionally on the 
hand, characterized by the formation of a sinus with a tendency to slow but 
deep and destructive ulceration, communicating with the surface by a small 
opening. It occurs after traumatism or undue pressure in a limb in which 
the nerve supply is interfered with. It thus follows spinal injury, congelation, 
posterior spinal sclerosis, syphilis, anaesthetic leprosy, and in animals from 
section of the sciatic nerve. 

A large single or multiple corn is first formed upon an exposed location, 
such as the lower aspect of the metatarsophalangeal joint of the first or fifth 
toe. Beneath the corn a sinus develops which ulcerates its way slowly inward 
until it involves soft parts and bones. The external opening is by the side of 
the original corn, and is sometimes surrounded with granulations; usually it 
is a small opening, but later, by continued pressure in walking, the epidermis 
becomes thickened into a large whitish-yellow mass surrounding the orifice. 

Attending the ulcerative changes are other lesions typical of tropho-neurotic 
affections. The epidermis becomes thickened, the nails altered, and the ex- 
tremity and dorsum of the foot gain profuse development of hair. There may 
be pigmentation, erythema or eczema, and increased or diminished perspiration. 
Anaesthesia is most common in and around the ulcer, while neuralgic and rheu- 
matic pains in the extremity are frequent. Variations occur in which either 
the ulcerative or neurotic symptoms are the more prominent. Hyde has re- 
ported similar cases involving both feet and hands. 

Pathology. — This tropho-neurosis may be due to injury to the terminal 
nerve, to the nerve-trunk or to the nerve centre. Gasquel reports sixty-nine 
central and eight peripheral nerve lesions among the ninety-one cases collected 
by him. "Destruction of the myelin and axis-cylinder of twigs of nerves sup- 
plying the affected part" has been noted. 



280 TROPHIC ULCERS— SYMMETRICAL GANGRENE 

Diagnosis and Prognosis. — When making a diagnosis the essential points 
of Maduro foot, tuberculosis and callositas should be considered, although the 
neurotic phenomena seen in perforation disease of the foot should make the 
distinction easy. Prognosis is doubtful. 

Treatment. — Complete rest and curettage of all diseased tissue is usually 
necessary, but the disease will often reappear as soon as the patient walks. 
Amputation, to be of any service, must be well removed from the diseased area, 
through healthy tissue. Arsenicum alb., and Populus cand. may be indicated 
internally. 

TROPHIC ULCERS 

Ulcers due to direct injury to nerves or to reflex irritation are considered 
to be trophic lesions. They spread serpiginously,-and are preceded and accom- 
panied -by neuralgic pain in the distribution of some particular nerve. They 
may form under vesicles or bulla?, leaving indelible, depressed or keloid scars. 
Such ulcers are sometimes gangrenous. In origin such cases would seem re- 
lated to dermatitis repens. Conium might prove a remedy in some instances. 



SYMMETRICAL GANGRENE OF THE 
EXTREMITIES 

(Raynaud's disease; Local asphyxia.) 

This is a rare affection and results from a spasm of the arterioles, causing 
venous stasis, and originates in some central or peripheral nervous disorder. 
Besides the extremities, the nose, ears, brows and other locations exposed to 
extremes of heat and cold may be attacked. 

The first indications of trouble are the signs of passive congestion, numb- 
ness, loss of sensibility, and pallor (local asphyxia, "dead fingers"). Then 
follow painful sensations, pricking, crawling, stinging or lancinating. If 
not arrested in this stage of cyanosis the process continues to superficial gan- 
grene. The skin becomes cold, firm and black, and the epidermis raised by 
serum in bulla?, which give way to persistent ulcers. A line of demarcation is 
soon formed and the necrosed parts are sloughed off. In mild cases the slough- 
ing is superficial and recover}- occurs, leaving the fingers thinned and covered 
with small white, tough cicatrices. Or the tissues may regain their tone with- 
out ulceration, or the nails alone rnay fall. 

Etiology and Pathology. — The causes of Eaynaud's disease may affect 
either sex and at any age, but more often men, and chiefly those in whom 
circulation is weak, with an unstable nervous system. Malaria, gout, diabetes, 
syphilis and tuberculosis are considered to be predisposing diseases. It often 
follows directly from exposure to cold, or the acute exanthemata, diphtheria, 
scarlet fever, etc. Pathologicallv it is essentiallv a nutritive disturbance 



AINHUM 281 

(tropho-neurosis) of the skin, the exact nature of which is not known. Beck lias 
demonstrated, hy means of the Eontgen rays, atrophic change in the boa 
two cases. 

The diagnosis will be readily made when there is a history of local asphyxia, 
and the location of the gangrenous process is found to be symmetrical, and on 
the extreme points of the body. 

The prognosis is often grave when the process is extensive and the general 
constitution poor. Disfigurement or mutilation is common, and recurrence is 
frequent. Death from the condition is rare. 

Treatment consists in efforts to improve general and local nutrition, re- 
move constitutional dyscrasia and neuropathic conditions by a nourishing diet, 
hygienic living, galvanism of the spine, and affected parts (high frequency 
currents have been used for the same purpose), stimulation and friction (if 
treated at an early stage) with alcoholic, camphorated or oily lotions, and ad- 
ministration of the indicated drug. See Secale. 



AINHUM 

(Banho-lcerende; Sulcha polcla; Quigila.) 

A singular disease found among the original inhabitants of Brazil, India 
and Africa is described by this native term, meaning "to saw." It is a degen- 
eration of the smaller digits, usually the little toe, following an annular 
constriction at its base, accompanied by increase in size of the member, and 
leading to spontaneous amputation. The constriction develops slowly from a 
semicircular groove at the root of the digit to a deep, narrow furrow encircling 
the toe, which strangulates and eventually detaches it without ulceration. 
Meanwhile slow degeneration occurs in all the elements of the toe, bones, ten- 
dons, vessels, etc., the toe increasing to two or three times its size, becoming 
globular or oval in shape. The process is very slow, extending from five to 
ten years or more. It is never congenital, and was formerly supposed to only 
occur in adults, but cases have been observed in children. Most cases end in 
the removal of the affected members. 

Etiology. — Male adults of the African race are the commonest sufferers. 
Trauma from self -mutilation or from the wearing of rings, lepra, scleroderma 
and heredity have all been claimed as causal factors,, but it would seem that 
to a tropho-neurosis from changes in the nerve centres, trunks or peripheral 
endings, must be assigned the chief causal agent. 

Pathology.— The epidermis becomes thickened and covers the constrict- 
ing ring, which is composed of fibrous tissue. The subcutaneous fatty tissue 
is increased, and the constricted bones undergo fibroid changes with enlarge- 
ment of the medullary spaces. Pathological investigations would seem to indi- 
cate that some cases of ainhum were similar to, if not identical with, sclero- 
derma annulare. 



282 SYRINGOMYELIA 

Diagnosis must be made from lepra mutilans, symmetrical gangrene and 
from those diseases of the nerve centres where fall of the digits may be occa- 
sionally noted. 

Treatment. — Incision of the constricting ring at an early stage is said 
to relieve the disease. Later, amputation of the toe, either where the con- 
striction occurs or at the proximal joint toward the limb, is a proper measure 
of treatment. Secale may be a good remedy in the early stage. 



SYRINGOMYELIA 

(Morvan's disease; Myelosyringosis; Analgesic paralysis with whitlow.) 

This disease of the central nervous system is usually accompanied by tropho- 
neurotio-^kin lesions. There are found ulcers, fissures, "glossiness," hyperi- 
drosis, vesicles, bullae, whitlows leading to necrosis with neuralgic pains and 
disorders of sensation. Identical or closely allied with it is Morvan's disease, 
another affection of the cord, characterized particularly by the formation of 
whitlows and necrosis of the phalanges. A deformity of the hand resembling 
the main en griff e of anaesthetic leprosy may be produced. It is believed by 
some to be an attenuated form of leprosy, but changes occur in the latter which 
are not found in the former, and pathologically they are probably unlike. 

Etiology is obscure. It is usually observed after puberty and more often 
in men than in women. Trauma, malaria and rheumatism have been men- 
tioned as possible causes. 

Pathology. — Cavities are found in the central canal, filled with fluid, 
supposed to be due to absorption of gliomata. Xeuritis and thickening of the 
neurilemma of the affected nerves, and sclerotic changes in the posterior 
cornua and columns of the cord, have been noted. 

Diagnostic signs are said to be the limitation to the upper extremities, 
the abolition of temperature and pain sensation, the preservation of tactile 
sensation, and the history or presence of some of the skin lesions above named. 
Just how the disease could be confounded with scleroderma does not appear; 
certainly the differences are well marked. The same may be said of anaesthetic 
leprosy and glossy fingers. 

Prognosis is doubtful, because the disease is chronic in its course and may 
persist for twenty years or more. 

Treatment. — A proper hygiene and diet are most essential. Surgical in- 
terference may be needed when medical means fail to relieve or cure. 



SCMBIES (ITCH) 288 



CLASS V.-PARASITIC AFFECTIONS 

This interesting group of cutaneous diseases includes widely different condi- 
tions when viewed from an anatomico-pathological standpoint, or even from 
their efficient behavior. They have, however, one feature in common, in that 
their efficient cause is an invasion of organisms on or into the tissues of the 
skin, from which they obtain nutriment and multiply at the expense of their 
involuntary host, and hence are parasitic. From this etiological relationship 
naturally follows, within certain limits, a correlated therapeutic principle 
which further justifies this classification. 

Parasitic diseases of the skin may be divided into (A) those due to animal 
Organisms, and (B) those due to vegetable organisms. 



A. ANIMAL PARASITIC DISEASES 

SCABIES (ITCH) 

Definition. — An animal parasitic disease due to the burrowing in the 
epidermis of the female acarus, resulting in multiple irritative lesions, 
which are aggravated by scratching. 

Scabies is one of the common diseases of the skin, occurring in from one 
to eight per cent, of all cutaneous affections, being sometimes more and again 
less prevalent. 

Symptoms. — The disease begins with the lodgment on the skin of the 
pregnant female itch mite, who seeks a thinner or more fixed part of the 
skin, and there proceeds, by tilting up her rear and forcing her head between 
the cells of the epidermis, to tunnel into the latter until completely buried 
within its substance. This much is said to be accomplished within half an 
hour. Soon after she deposits an egg, burrows further on, laying each day 
one- or two or more eggs, until about fifty have been successfully deposited in 
a burrow inclining inward in an irregular, tortuous or rarely straight line. 
The length of the coniculus or burrow is usually from one-eighth to three- 
eighths of an inch, but may be much longer. On the surface the burrow shows 
in cleanly persons as white or delicately gray dotted lines, but more often they 
are brownish or black from the entanglement of dirt in the slightly roughened 
epidermis. On section and microscopic examination the burrows arc found 
to contain besides the mother mite, eggs, egg-shells, larva?, nympha?, and dark 
specks supposed to be faeces. During the passage through the epidermis the 
mite may sometimes be seen at the end of the dotted line as a small white 
speck, and then may be removed on the point of a needle. Left to her course 
the deposit of ova is completed in about two months and she dies. Long 
before this some of the earlier laid eggs have hatched out (estimated to occur 



284 SCABIES (ITCH) 

into larvae within a week, and into adult acari within three weeks), and have 
escaped on to the surface either by the natural shedding of the epidermis or 
by ruptures in the roof of the burrow. The surviving female portion of the 
progeny become impregnated and in turn seek the seclusion of the epidermis to 
deposit ova and to die. Meanwhile the male acarus is supposed to roam over 
the surface, hide under or become entangled in the scales or crusts, with no 
share in the cutaneous business except that of impregnation. The work of 
the female acarus briefly outlined produces in proportion to the sensitiveness 
of the individual skin early consecutive lesions of papules, vesicles, pustules, 
wheals, bullae, crusts, which may be further added to or aggravated by excori- 
ations from scratching in attempts to alleviate the attendant itching. Pruritus 
is nearly constant, not always limited to the affected portion of the skin, and 
varies in degree in different persons, but is invariably worse at night, the 
warmth of the bed especially stimulating the activity of the parasite. Ari 
advanced case of scabies may show no signs of the pathognomonic burrows, 
they having been obliterated or obscured by the polymorphous lesions common 
to types of eczema. The eruption tends to occur, however, in isolated lesions 
rather than in groups as in eczema, and the localization also differs somewhat 
from the latter. Thus the sites of predilection are the hands, especially the sides 
of the fingers and inter-digital folds, and more protected parts of the surface 
which are habitually or easily touched with the hands, such as the wrists, 
elbows, breasts, axilla, umbilicus, penis, buttocks and thighs. Infants at the 
breast may contract the disease in the act of nursing, and exhibit the burrows 
on the face, and in children the toes as well as the soles and palms may 
become infected. Pustular lesions are more common and extensive also with 
scabies occurring in children, owing to the less resistance of the skin to ex- 
citers of inflammation at this early age. In rare instances when all methods 
of cleanliness are avoided or from pathological changes in the skin (anaesthesia) 
the usual sensations are not felt, the acari may multiply in large numbers, be- 
come widely distributed, and the lesions assume aggravated pustular forms, 
going on to the formation of furuncles, cellulitis and thick crusts, the latter 
swarming with parasites. This variety has been called "Norwegian itch" or 
scabies crust osa and has been observed in its greatest intensity in neglected 
cases occurring in lepers. 

Etiology and Pathology. — The sole efficient cause of scabies is the de- 
posit of ova between the cells of the epidermis by an impregnated acarus. 
Favoring conditions are uncleanliness of the skin, intimate and prolonged con- 
tact of one person with another as in infants nursing at the breast or two 
persons sleeping together in one bed. Handling of animals affected with the 
disorder, such as cats, dogs, horses, camels, may be the method of origin ; 
but the colony thus started rarely persists or thrives. The same may be said 
of the human acarus when transferred to the lower animals. It is doubtful 
if the parasites are ever transferred by mere transient contact or through 
the medium of articles worn or handled. No age, sex or station is exempt, 
though it is seldom seen in the cleanly, and is most common before the age 
of thirty. 



scabies (rrcH) 286 

The pathology of scabies is chiefly concerning the nature of the parasite, 
the cutaneous lesions being essentially an artificial dermatitis therefrom. The 
mature female acarus which is the cause of the disease can be just discerned 
by the unaided eye as a white, shining, roundish body, which mounted in 
glycerine and examined microscopically is found to be provided with eight 
conical legs; to each of the forelegs is attached a sucker, and to each of the 




Fig. 77. — Acarus Scabiei (female). Fig. 78. — Acarus Scabiei (male). 
(Ventral surface ; x about 100; diagrammatic after Duhring.) 

rear legs a bristle. There are also a few short bristles on the back and on 
the under surface, and sometimes an ovum may be seen in the centre or pos- 
terior part of the under surface. The male acarus is about two-thirds the 
size of the female, has well-marked genital organs, and for the purpose of 
copulation has a small sucker on each of the posterior pair of legs. 

Diagnosis. — When the pathognomonic cuniculus can be found in a case 
of suspected scabies the diagnosis is readily made. The use of a magnifying 
lens will sometimes facilitate the search for the burrow. Dark lines or dots 
of dirt upon the surface may be mistaken for the acarus lesion, but wiping the 
skin with a damp cloth will remove the former and not affect the presence of 
the latter. If a burrow is foiind and the acarus is still alive and shows at the 
further (and slightly redder) end as a whitish speck, the epidermal cover may 
be carefully broken open at this spot with a needle held obliquely to the sur- 
face of the skin, and the acarus lifted out on the point. In the absence of any 
traces of the burrows the location and the irregular distribution of the erup- 
tion, especially if in isolated pustules, and the separate scratch marks will 
be significant. A history of similar cases in the same family or house may 
help to establish the nature of the disease. Aggravation of the itching from 
the warmth of the bed in association with other symptoms of scabies is diag- 
nostic. 

The vesicles and pustules of eczema are usually grouped, and do not ex- 
hibit the same localization or separate excoriations as in scabies. The erup- 
tions of eczema, syphilis or impetigo contagiosa may at times coexist with 



286 SCABIES (ITCH) 

scabies and greatly complicate its clinical expression. In all doubtful cases 
a few days' antiparasitic treatment will cure or greatly improve scabies or an 
associated impetigo, but would leave the more chronic affections unaffected 
or aggravated. 

Prognosis. — This is always good for uncomplicated cases which submit 
to proper treatment and take precautions against reinfection. 

Treatment. — Causal or antiparasitic methods are always indicated. These 
should be adapted in strength and other qualities to each individual case. 
Sulphur ointment for every case of scabies is injudicious and unsatisfactory 
in results as it is empirical in art. The first object of treatment is to thor- 
oughly cleanse the surface and remove the outer layers of the epidermis so as 
to expose and break up the burrows which contain the mature, maturing or 
embryo acari. This may be accomplished by frictions with soap in a hot bath, 
if the-djsease be general, or with local hot water and soap bathing, if the 
disease is local. For thin and delicate skins any ordinary soap will do; for 
the less sensitive stronger soaps may be employed, while for the thick skinned 
and dirty, soft soap or diluted sapo veridis is the most serviceable. The same 
discretion should be used as regards friction, employing coarse toweling, a 
flesh brush, a nail or horse-hair scrubbing brush as the case may warrant. 
These preparatorj*- steps should be thorough without irritating the skin. Imme- 
diately after the scrubbing process the affected skin should have applied to it 
some antiparasitic, which may vary with the condition of the skin, the age and 
circumstances of its owner. In public practice sulphur ointment is the most 
efficient and convenient application. It may be ordered in the strength of 
a half to three drachms to an ounce of fresh lard; one to eight is an average 
and effective strength. This should be applied thoroughly once a day (prefer- 
ably at night) for two or three successive days, and followed at the end of 
this time by a warm bath, when, with a change to fresh underclothing and 
bed linen if possible, the cure is usually complete. If an} r irritation of the 
skin remain or result from treatment, simple vaseline may be applied as 
needed, and if any signs of the disease remain after a few days the sulphur 
applications may be repeated. AYhen the preliminary bath cannot or will not 
be taken, the above anointing with sulphur may need to be somewhat stronger 
and longer continued, three to seven days. In generalized scabies the patient 
may be kept in bed for forty-eight hours if practicable; most cases may be 
allowed to go about as usual, not changing their clothing until the final bath 
is taken. In place of the offensive ointment, sulphur powder may be rubbed 
on to the skin, and a half teaspoonful placed between the sheets of the bed 
at night as suggested by Shirwell. 

NapMhol is an excellent substitute for sulphur, and is especially to bo 
recommended for use in private practice in the proportion of twenty to sixty 
grains to an ounce of lard. 

The following has been found efficient in an average case : 

J$. B-Naphthol pulv gr. 50. 

Adipis rect o 1|- 

Aq. rosae gtt. 25. M. 



SCABIES (ITCH) 287 

This has the advantages of being without color or unpleasant odor, and 
seldom excites a dermatitis or aggravates an associated eczema as sulphur is 
very liable to do. The details of application are the same. In patients with 
thick and inactive skins sapo veridis may be added in one to i'our of the 
above as in Kaposi's formula. I have never found it needed when the direc- 
tions for bathing were carried out. The possibility of naphthol affecting the 
kidne} r s when it is too freely used on inflamed skin should always be borne in 
mind and the urine watched. 

For scabies occurring in women and children with delicate skins styrax 
mixed in ointment or oil is an agreeable and unirritating application. 

1$. Styracis liquidi 3 1. 

Adipis §2. M. 

Olive oil may be substituted for the lard in the above, and balsam of Peru 
in small proportion (twenty drops to the ounce) is sometimes added. Styrax 
used too freely shares the same objection as naphthol, that it may irritate the 
kidneys. A resinous substance may be sometimes found in the urine from its 
over use. Carbolic acid, balsam of tolu, staphysagrla, tar, oils of cinnamon, 
rosemary, mint and cloves and petroleum have been used, but present no 
advantages, unless a strong odor be considered beneficial, over the prepara- 
tions mentioned. 

In institutions possessing the conveniences, quick cures of scabies may be 
made by the so-called French method as long practiced at the St. Louis Hospi- 
tal in Paris. There the scabies patient is first, scrubbed with green soap and 
water for half an hour, then given a hot bath of an hour's duration, after 
which follows a thorough rubbing all over the body with an ointment composed 
of sulphur two parts, potass, carbonat. one part and lard twelve parts; the 
patient resumes his clothing without removing the ointment, and is then dis- 
charged cured. The one treatment is effective in nearly all cases. Few Ameri- 
can skins could stand this heroic method without a resulting dermatitis liable 
to give more suffering than the original disorder. It may be adapted, however, 
to occasional "tough" examples of the disease. To prevent a relapse of scabies 
patients should be told that all members of the family exhibiting similar erup- 
tions must be treated at the same time. At the end of treatment the bed 
linen and clothing worn next to the skin should be put in boiling water, baked 
or disinfected if practicable or convenient. As, however, the acarus, larvae or 
eggs do not long retain their vitality away from living tissue, laying the cloth- 
ing aside for a few days is effective in the w r ay of prevention. In Vienna it is 
said no attempt is made to sterilize the clothing of scabies patients, witli the 
result that only one per cent, of cases relapse. In all cases where indications 
are found for a drug remedy it should be administered to increase the resist- 
ance of the skin, but no one who cares for the golden rule would think of wait- 
ing on that alone to effect a cure. Among remedies see Cal. sulpli.. Merc, P.<or. 
and Sulphur. 



288 PEDICULOSIS— PEDICULUS CAPITIS 

PEDICULOSIS 

(Phthiriasis; Lousiness.) 

As the acari represent the most common form of dermatozoa, parasites liv- 
ing for a time in the skin, so pediculi represent the most common kind of 
epizoa, parasites which roam on the skin for a time to obtain nourishment. 
They are wingless insects provided with eyes and with biting., sucking and 
masticating parts. In obtaining food they make an opening in the skin with 
mandibles, and then insert the head therein and suck blood from the papillae. 
The pediculi which infest the human skin live near by in the clothes or hair, 
and consist of three varieties, which, according to their location, are called (A) 
pediculus capitis, (B) pediculus corporis and (C) pediculus pubis. 

A. PEDICULUS CAPITIS 

{Head louse.) 

Without producing any direct lesion, the presence of this insect usually 
excites so much itching that the efforts to relieve it by scratching soon result 
in excoriations, which may become eczematous, or infected with pus cocci and 
become transformed in neglected cases into impetigo contagiosa lesions, furun- 
cles and small abscesses. The favorite seat of the pediculi is the occipital 
region, where the hair is thickest, and here the most marked lesions are 
found, often consisting of crusting pustular formations of small and large 
size. In exceptionally dirty and neglected cases the hair may become matted 
together with the exudation of serum.' pns, mingling of dust, scales, scabs and 
other debris, and swarming with pediculi, constituting the offensive mass known 
as plica polonica. Pediculi of the head may invade any and all parts of the 
hairy scalp, but never go beyond its limits, though occasionally the skin is 
erythematous and eczematous outside the hair border, especially down upon 
the neck. In cases of long duration the glands of the neck may be swollen 
and the neighboring superficial lymph glands may become enlarged, tender 
and inflamed even to suppuration. In the healthy and vigorous a few pediculi on 
the scalp may give rise to little disturbance for a time beyond a slight itching, 
the conditions not seeming favorable to their activity and propagation. "While 
it may be difficult to find the live pediculi in these cases, their eggs may be seen 
more readily than when resulting lesions have been added. The ova or "'•'nits'' 
will be found as minute, whitish bodies firmly glued to one side of the hair. 
When the pediculi are few in number usually only one egg is found upon a 
hair, but as they multiply several may be seen at short intervals on one shaft. 
In all cases of pediculosis the nits can be found on careful search, and gener- 
ally one louse or more will be discovered. The latter appear on the hair or 
scalp as small, grayish bodies to the naked eye, which on being disturbed are 



PEDICULUS CAPITIS 



289 



seen to In' alive. They arc said to van' m color somewhat with the color of the 
hair and skin. 

Etiology \m> Pathology. — Pediculosis of the Bcalp is always conveyed 
from one person to another l>\ contact, or through the medium of bats, caps, 
combs, brushes, pillows, etc. The subsequenl multiplication of the pediculus 
is favored by uncleanliness and lack of habitual combing or brushing the hair. 
'Thcv may, however, be transferred to and propagate on the clean and well- 
cared-for Bcalp, and at any age, although most often an affliction of childhood. 

The head louse is aboui two millimetres long by one wide the female out- 




Fig.79. — Pediculus Capitis. Fig. 80. — Pediculus Corporis. Fig. 81. — Pediculus Pubis. 
(Dorsal surface of female; x about 25; diagrammatic, after Duhring. ) 



ranking the male in size and number. The sexual organ of the male is situated 
on the hack, so that copulation is effected by the female sitting upon The male. 
The female is very prolific, laying upwards of fifty eggs; these hatch out in 
ahout a week, and fully develop in about a week more. A single pregnant 
female unmolested may give origin to a numerous family in a few weeks (esti- 
mated at five thousand in eight weeks), which by their presence give rise to 
surface lesions not unlike those of eczema and other pustular affections. 

Diagnosis. — Unexplained itching of the seal]) may always arouse a sus- 
picion of pediculosis, especially in the uncleanly, while a pustular eruption on 
the occiput is a strong presumptive indication of the presence of pediculi in 
the same class. The diagnosis can he made positive by a discovery of the 
insects or their ova, which is nearly always possible. 

Treatment. — As in scabies, the first object is to remove the cause In 
public practice this may he accomplished by saturating the scalp for two or 
three nights with kerosene nil and constantly wearing a closely lining cap 
covering the whole hairy scalp, care being taken not to allow the oil to run 
down upon and irritate the adjacent skin, It is wise also to caution the 
heedless against the danger of setting on tire oil-soaked hair. In young chil- 



290 PEDICULUS CORPORIS 

dren the hair may be cut close, as thus many of the nits are removed and a 
cure expedited. It is not necessary to sacrifice the hair, especially the long hair 
of women, as antiparasitics and cleansing will certainly effect a cure. When 
the odor is unobjectionable the use of carbolic ointment, as recommended by 
Greenough, is efficient: 

Py. Acidi carbolici qrs. 15-25 

Ung. petrolii 5 1. M. 

Applied to the affected regions once or twice daily, this kills the pediculi 
and sterilizes the nits and other incidental organisms. Likewise one drachm 
of the powdered seeds of staph ysagria to an ounce of vaseline, or the officinal 
ointment of ammoniated mercury can be used for the same purpose, but where 
there are open sores the latter should be diluted after one or two applications. 
NaphtJiol in the same form as suggested for scabies will be serviceable in 
milder--cases, or following stronger applications in the more severe. What- 
ever oily application is employed, the scalp should be thoroughly cleansed 
every day or two with soap and water, or borax and water, and to remove 
the dead nits ordinary vinegar or diluted acetic acid may be used. Either 
of the latter, with after-combing and brushing of the hair, will soon rid 
the scalp of all remnants of the pediculi and their products. Antiparasitic 
soaps are convenient for use either alone or after other applications to 
prevent relapse. Corrosive sublimate soap one-half per cent, or creolin soap 
ten per cent. I have found efficient in recent cases. The whole scalp is well 
rubbed with a lather of the soap, then cleansed with warm water, dried and 
sometimes a little white vaseline or olive oil applied to the more tender parts 
to prevent undue irritation. This can be repeated daily as long as needed. 

B. PEDICULUS CORPORIS 

(Pedicwiits vestimenti; Phthiriasis; Body louse; Clothes louse.) 

This is the largest of the three varieties and dwells in the clothing, only 
foraging on the skin to obtain food. They seek the folds or seams of the clothes 
most constantly in contact with the skin, and thus are found generally hid- 
ing in the garments about the shoulders, neck, thighs and waist. They are 
seldom found on the skin, but occasionally may be caught on the surface as the 
patient suddenly removes the underclothing, when one or two may be seen 
hurrying to find some place of concealment. From their habit of seeking cover 
quickly they do not wander far on the skin, and their lesions are often limite*! 
to the regions above mentioned. When hungry they leave their lodgings, and 
as Swammerdam originally pointed out (since verified by Schjodte),they insert 
into the skin a haustellum through which the blood is sucked up to the head 
of the parasite. As the sucking organ is withdrawn from the skin blood wells 
up through the aperture, making a minute hemorrhagic speck on the sur- 
face. The injury inflicted by the pediculus, with possibly the injection of 



PEDICULUS CORPORIS - ; " 

some irritating substance, produces a wheal-like Lesion around the blood-marked 
wound. This is attended with intense itching Leading to energetic scratching, 

in which the wheals are torn through with the nails, leaving a rather broad, 
deep and bloody excoriation. The pruritic sensations are qoI confined wholly 

to the injured spot, so that other and less pronounced Bcratch marks may be 
seen in the same or other regions. As the deeper excoriations disappear pig- 
mentation is apt to mark their sites for several weeks; these may Later be 
replaced by white atrophic or cicatricial looking lino. Sometimes then 
more or less sympathetic eruption of miliary papules scattered about the trunk. 
In comparatively recent cases any or all of the above lesions may be found on 
the skin. In long-standing cases, or in which pediculosis has existed at fre- 
quent intervals for many years, there may be an extreme polymorphous condi- 
tion of the skin, particularly in the classical locations, and often of wider 
extent. Mingling with recent lesions above described may be found pustul 
crusts, more or less diffused dermatitis, furuncles, abscess, deep pigmentations, 
etc. Occasionally grayish-brown to blackish-brown staining of the surface may 
be extensive, with or without the other aggravated lesions. A patient in my 
service at the Metropolitan Hospital presented a very general pigmentation 
of the skin from the neck to the knees due to repeated pediculosis. It is 
probable, as Kaposi has suggested, that some cases of reported Addison's disease 
were examples of pigmentation from pediculosis. Crocker mentions occa- 
sional pyrexia as a symptom, when the pediculi are numerous, especially in 
young persons. The worst types of the disease occur in the more chronic and 
degenerate tramps in whom change of clothing is of minor importance. Hence 
the term "vagabond's disease." 

Etiology and Pathology. — Predisposing causes arc poor conditions of 
general and surface health from lack of food, cachexia, old age, uncleanliness, 
etc. Vigorous and cleanly persons are rarely afflicted with pediculosis corporis. 
If the insect accidentally finds lodging in the clothing, habitual changing of 
the latter and bathing soon result in permanent eviction. The efficient cause 
is always a transference of the pediculi or their ova from one person directly 
or indirectly to another. The pregnant female lays her eggs in chain-like order 
in the seams or folds of the garments near the skin, to there incubate and 
mature if undisturbed. The color of this pediculus is a dirty white with 
blackish sides. 

Diagnosis. — In suspected cases, after the patient is partly undressed, care- 
ful search should be made in the seams and bands of the clothing next to the 
skin, especially about the neck, for signs of the pediculus or ova. This can be 
done without arousing the suspicion of the patient, while apparently examin- 
ing the surface of the back, nates, etc. Unless the clothes have been recently 
changed the search will not usually be in vain. But even without being able 
to produce the corpus delicti the presence in the characteristic locations of 
minute hemorrhagic points, wheals, broad linear excoriations, pigmentations. 
and their absence on the hands and wrists will afford diagnostic evidences of 
the disease. No other affection with similar lesions would be limited to the 
same regions. 



292 PEDICULUS PUBIS 

Treatment. — This can be directed towards the clothes rather than the 
patient. No cure can be expected while the infested clothing is worn. When 
expense is not a necessary obstacle, the underclothing had best be buried or 
burned, but they can be sterilized by boiling or baking at a temperature of not 
less than 212° F. The bedding, or at least the bed linen, should be treated 
in the same manner. With the foregoing precautions against reinfection, the 
patient with a supply of fresh clothing is practically cured. A thorough bath 
with some antiseptic soap, like boric acid or creolin, and water is advisable. 
Cutaneous eruptions remaining usually require, only protective treatment as 
indicated for other kinds of symptomatic dermatitis, or by indicated physio- 
logical methods and drugs when systemic or functional derangements also 
exist. 



^ C. PEDICULUS PUBIS 

(Phthiriasis pubis; Crab louse.) 

Symptoms. — As the name foretells, this variety is found alone or chiefly 
on the hairy surface of the ]->ubic region. With increase of number they may 
find their way or be transported to the hairy parts of the abdomen, thorax, 
axilla?, beard, and in the uncleanly may be found on the eyebrows, eyelids or 
lashes. They are said never to invade the scalp, although two exceptions have 
been recorded, both in infants. Occasionally they may be confined to the hairy 
parts of the upper segment of the trunk. In one case under my observation 
they were very numerous in the axilla?, while none were to be found in the 
pubic region. The habits of this species are like the pediculus capitis; it is, 
however, less active, smaller in size, and may be usually found clinging to 
one or two hairs where they emerge from the skin, with its head buried very 
deeply in the hair follicle. This digging into the follicle generally excites 
intense itching, and papular or more severe eczematous lesions result, but some- 
times the disturbance is very slight. In some cases when scratching is not 
excited or for some reason not indulged, bluish or brownish, round or irregular, 
finger-nail sized pigmented spots have been observed deep in the epidermis of 
the affected area. These so-called maculae cerulece are more distinct in light- 
skinned persons, and are believed to be due wholly or in part to the subepi- 
dermic infection of saliva by the pedicurus from salivary glands situated 
opposite its forelegs. Some believe the effect of this secretion is to produce 
anaesthesia of itching without affecting other sensations. The spots fade away 
within a few clays after the destruction of the parasites. Hemorrhagic specks 
may be often found, and in long lasting cases considerable eczema is apt to 
develop, sometimes extending beyond the hairy parts of the skin. The nits 
are similar to those of the pediculus capitis, and are found glued upon the 
hairs in the same way. 

Etiology axd Pathology. — While less common than pediculosis capitis 
this variety is more often encountered in the well-to-do. and in the majority 



INSECT BITES 298 

of cases from contact during illicit sexual intercourse. It may be, however, 
communicated through the medium of beds, clothing, water closets, etc The 

pubic louse is less prolific; than the head louse, but the ova hatch out and 
mature in about the same length of time. 

Diagnosis. — Close investigation will always reveal (in true cases) the 
presence of the pediculi clinging to the hairs close to the skin. They are not 
easily disturbed, and it requires a little force to dislodge them; the ova can 
also be found. It is well to carefully inspect the pubic and other hairy regions 
in all cases of persistent pruritus of those parts. 

TREATMENT. — Two things need not be done: the hair need not he cut 
or shaved off, as it exposes the parts to friction from the clothes, and mercurial 
ointment should not be applied, because it is no better than less nasty para- 
siticides and often causes a dermatitis. Solutions are to be preferred to 
ointments, as a rule. Infusion of tobacco, tincture of cocculus, or corrosive 
sublimate, one to two grains to an ounce of cologne, are serviceable applica- 
tions. When there are eczematous lesions naphthol ointment, one drachm to 
an ounce of lard, is to be preferred; it may he reduced in strength for the 
further relief of the eczema when the pediculi have been destroyed. If pru- 
ritus is extreme or persistent, carbolic acid, one to forty, in lotion or ointment, 
is efficient. 

Eecovery from persistent or chronic pediculosis may he hastened by the 
use of such drugs as Psor'inum, Staph, and Sulphur. 



INSECT BITES 

Pulex irritans. — The common ^ea pricks the skin to suck blood therefrom. 
A reddish swelling immediately forms around the puncture, but soon sub- 
sides unless the skin is delicate, as in women and children; then small, urti- 
carial-like wheals may remain for a few hours and be distinguished for a 
time by the central puncture. A punctate (petechial) hemorrhage at the 
point of penetration is the usual result, lasting for several days, and when 
the lesions are numerous resemble purpura simplex, passing through the 
same gradations of color. 

A diagnosis is easily made by an absence of symptoms of other affections, 
a discovery of the insect and the central puncture in recent lesions. 

Treatment may call for weak carbolic acid or boric acid lotions. Stel- 
wagon recommends the wearing of bags filled with gum-camphor beneath the 
clothing in the same manner that sulphur has been used. 

Pulex penetrans. — The jigger or sand flea is a minute brownish-red para- 
site which may penetrate the skin of man and of the lower animals. Only fecun- 
dated females do the damage, and the bad. results are said to arise "from 
distension of the ovary of the parasite which may exceed fivefold the original 
dimensions of the insect." It is found in the sandy regions of South America 
and the West Indies, and attacks usually the uncovered feet at the side of the 



294 . INSECT BITES 

toe-nails, boring underneath with scarcely painful sensations. Less commonly 
it attacks other parts of the foot, the knee, scrotum, back, etc. If allowed to 
remain in the skin, the presence of the insect excites inflammation, suppura- 
tion, and sometimes gangrene. The treatment consists in the early removal 
of the flea with a blunt-headed needle or probe, and local antiseptic applications 
adapted to the degree of inflammation. Anointing with essential oils or car- 
bolized oil is said to be preventive. 

Cimex lectularius. — The common bedbug would need no mention were it 
not that the lesions it produces are sometimes mistaken for urticaria, or the 
excoriations of pruritis essentialis. This animal only visits the human skin to 
feed. With systematic order it bites into the skin, injects therein the irri- 
tating contents of its salivary gland to produce an immediate increase in the 
flow of blood, and then proceeds to suck its fill of the latter. A raised reddish 
spot, with a lighter centre and central puncture, remains. This becomes pur- 
puric and finally fades away in the usual manner. Itching is caused by the 
irritated wounds, and scratching is apt to leave linear and other excoriations. 
Eeal urticarial wheals may arise away from the point of injury, and some 
believe that cases of urticaria may be caused by repeated attacks and persist 
after the parasites have been destroyed. A diagnosis may usually be made 
from urticaria and pruritis in recent cases by tbe central puncture in the 
lesions, their most distinct appearance in the morning, fading during the 
day, and sometimes by finding the suspected insect in the crevices of the bed 
or adjacent walls of the room, or cracks in the floor. 

The only effective treatment is by a war of extermination on the para- 
site, or by a retreat of the victim to a safe distance. The local application of 
alcohol, spirit of camphor, tincture of ledum or weak carbolic acid solution, 
will relieve the irritation. 

Culex pipiens, etc. — Mosquitoes and gnats, bees (Apes melliferae), midges 
(Simulia), and wasps (Vespidae), when they attack the human skin, produce 
wheals, oedema, and sometimes ecehymotic lesions, attended with pain and itch- 
ing. The patient is usually aware of the cause of the eruption, and the puncture 
made by the insect can usually be seen. The discomfort arising from the 
eruption may be speedily allayed by rubbing it with spirit of camphor, am- 
monia water or baking soda, and then douching the part with cold water. 

Leptus autumnalis. — The harvest bug. or mower's mite, is a minute red- 
dish insect, visible to the naked eye, which may be found in the summer and 
autumn on the grass and bushes, and when accidentally lodged upon the skin 
of persons working in the field or garden may burrow its head in a follicle. It 
can be seen sometimes as a yellowish-red spot on the skin of the ankles, legs, 
feet and arms. It does not long survive on the skin, but in the meantime may 
give origin to a slight eruption of papules or wheals. These quickly subside 
spontaneously, or on the application of alcohol, spirit of camphor, or any 
anti-pruritic lotion. 

Ixodes ricinus. — The female of several species of wood-ticks may be a 
transparent parasite on the human skin. It bores into the skin with its pro- 



FILARIA MEDINEN8I8 295 

boscis, and sucking the blood, fills itself to repletion; presenting at this time 
the appearance of a pea-sized sac. It soon falls off, to return to the trees and 
await on hunger and another victim. If found on the skin, it should not be 
removed forcibly, as this might leave its proboscis in the wound and result 
in much pain. It may be left to fall off spontaneously, or be induced to 
quit at once, and, at the same time, killed by painting it with spirit of turpen- 
tine or by applying tobacco juice. 

Dermanyssus avium. — These mites live on birds and fowls, and may be 
numerous in bird-cages and hen-houses. When they attack the human skin 
they cause a papular dermatitis, which subsides spontaneously. 

Apis, Crotalus, Ledum or Rhus tox. may be indicated for troublesome or 
persistent lesions from insect bites. 



FILARIA MEDINENSIS 

(Dracunculus medinensis; Guinea-worm.) 

This is an affection of tropical countries. It is not known positively how 
the embryo worm reaches the epidermis, whether through the intestinal track 
or from without through the surface. It is said to produce no general or 
local disturbance until mature, when some part of it may be felt like a small 
whipcord under the skin. It may migrate to some distance from the point 
of discovery, consuming weeks or months before finding its choice for exit; 
and if the parts traversed are thin, as along the fingers and over the joints, 
it causes considerable pain; in its passage through the fleshy tissues there 
may be felt only tension and uncomfortable fulness. Finally, after a variable 
time, it approaches near the surface, a vesicle, pustule, or tumor-like abscess 
forms, at the bottom of which rests the head of the worm. The place of exit 
is, in the majority of cases, on the foot, especially the heel; less often it may 
be on the leg or thigh, and rarely on the scrotum, hand, trunk, head, nose and 
orbit, but it has never been found in the brain or eye. Commonly there is 
only one worm, but there may be several, and rarely many. If much inflamma- 
tion results from the presence of the worm, or its death in the tissues, serious 
results may follow from suppuration, gangrene, hectic fever, which may ter- 
minate in death from exhaustion or tetanus. 

Etiology and Pathology. — The published reports of studies of the evolu- 
tion of this nematode worm make it almost certain that the larva? enter the 
body through the drinking water. The embryos develop into larvae in the 
body of a minute aquatic animal organism, and when accidentally swallowed 
in water by man the larva? escape in the gastro-intestinal tract, undergo further 
development and impregnation, and some, including all the males, are sup- 
posed to be expelled in the faeces. The surviving females make their way into 
the tissues, maturing as they go, until the new generation of embryos are ready 
for a further stage of evolution within the body of the lower aquatic animal 
first mentioned. Then the maternal worm seeks an exit on the surface, having 



29(5 CYSTICERUS CELLULOSE CUTIS— ECHINOCOCCUS 

attained the dimensions of about one-tenth of an inch thick by one to three 
or four feet long, and a cylindrical or slightly flattened shape. 

The disease is endemic on the coast of Guinea, border of the Persian 
Gulf and Caspian Sea, in upper Egypt, some of the East and West Indies'. 
Brazil, etc. 

Diagnosis. — This cannot be made with certainty until the worm approaches 
the surface and can be felt as a cord-like line under the skin, and change of 
position is observed before the lesion of exit is formed. Its endemic character 
should be remembered. 

Treatment. — Where the disease prevails generally the natives are said 
to extract the worm by suction after the head has appeared, or by traction 
from running water, the foot being placed in a flowing stream for the pur- 
pose. The usual directions are to secure the head of the worm after the 
opening occurs in the skin, and draw out as much as will come easily without 
danger of breaking the worm. The extracted portion is wound around a piece 
of pasteboard, and a turn or two given each day until the entire length is 
drawn out. This may take several days or weeks. The best treatment is that 
devised by Emily, who injects in several places a solution of mercuric chloride 
(1: 1000) into the SAvelling produced by the worm before she has pierced the 
skin. This kills the worm, which may be absorbed or removed by incision. If 
the head has appeared, then the solution is injected directly into the body, 
which may be removed the next day. Tims the length of treatment is reduced 
to four or five days. 



CYSTICERUS CELLULOSE CUTIS 

The hydatids of taenia solium are sometimes found in pea-sized tumors in 
the subcutaneous tissue and covered by unchanged skin. They arc most often 
seen in countries where half cooked or raw pork is commonly eaten containing 
the ova of ta?nia. If the tumors are punctured a clear fluid will run out in 
which may be found the pathognomonic booklets. The cutaneous lesions are of 
importance only in relation to hydatids of some internal organs. 

Diagnosis must be made from gumma, lipoma, epithelioma and sarcoma. 



ECHINOCOCCUS 

The larvae or hydatid of the taenia echinococcus of the dog has been found 
in the human skin by Weyl, Geber and Davaine. This parasite becomes encap- 
sulated, forming soft tumors or vesicles which produce a sensation of tension 
and which undergo fatty degeneration after the death of the parasite. 

Kiichenmeister has reported the presence of the embryos of the large liver- 
fluke (distoma hepaticum) encapsulated in subcutaneous tissue. 



DEMODEX FOLLICULORUM— FA V is 297 



DEMODEX FOLLICULORUM 

Demodex folliculorum was discovered by Eenle in 1841, and is a micro- 
scopic worm-like insect found in comedo-plugs, in open sebaceous glands, in 
cases of acne and seborrhcea oleosa, as well as in normal cases. Pigmentation 
of the skin has been reported as traceable to this parasite. 



B. VEGETABLE PARASITIC DISEASES 

FAVUS 

{Tinea favosa; Tinea vera; Tinea lupinosa; Porrigo lupinosa; Porrigo favosa; 
Crusted ringworm; Honeycomb ringworm, etc.) 

Definition. — A contagious parasitic affection of the scalp and other 
parts of the skin, due to a fungus growth, and characterized by cup-shaped, 
pale-yellow, split-pea sized or smaller, discrete or confluent crusts. 

Symptoms. — The disease usually begins first on the scalp, but may occur 
upon any part of the skin and with extreme rarity on the mucous surfaces. 
In the early stage it appears as a circumscribed or diffused inflammation, with 
moderate sealing, followed in a short time by the formation of yellowish pin- 
head crusts at the hair follicle and commonly around the hair shaft close to 
the surface. These are concave from the first, but as they increase in size 
and elevation the circular cup shape becomes more apparent, especially in 
isolated lesions. Here the more elevated rim may be of a darker color from 
admixture of epidermic cells and dust in contrast with the less elevated, stri- 
ated, pale, sulphur-colored centre, sometimes distincl enough to appear like 
two separate formations. The term funis lupinosus has been used to desig- 
nate the single isolated lesion. The favus crusts are friable and can be pow- 
dered between the fingers: they are often aggregated into masses, sometimes 
preserving a round shape only at the free border, funis squarrosus-. If the 
scutula are removed, the surface underneath is found irregularly depressed. 
in which depression has rested the corresponding uneven, moist under sur- 
face of the crust. The depressions in the rete soon till out after removal 
of the crusts; occasionally the papillae are torn by separation of the crust and 
bleeding occurs. Inflammation in various degrees may occur, sometimes pus- 
tular, and in rare, long-lasting cases it may be ulcerative in character. The 
products of inflammation, the admixture of dirt, or medicated applications 
may change the color of the crnsts in advanced cases to a greenish-yellow or 
brownish hue. When the favus cups are fully formed, after a variable period 
of months, the crusts fall off spontaneously or from accidental friction, leav- 
ing hairless, white, atrophic spots to mark their former sites. These may 



298 FAVUS 

be permanent and, rarely, the atrophy may extend to the subcutaneous tissues ; 
even atrophy and necrosis of the bones of the skull have been reported. On the 
scalp the hair is usually affected, becomes dry, brittle, lustreless, splits or 
breaks off, gets loose from its attachment and falls or is easily drawn out ; if 
not regenerated and pressure continued the papillae and follicle may be obliter- 
ated, and partial or complete baldness remain over a less or greater extent 
of the scalp. 

The nails are rarely attacked with f avus, and then it is nearly always com- 
municated by scratching the scalp. It begins usually at the free border of the 
nail, but may appear in the centre or near the lunula. In the substance of the 
nail it may appear through the smooth outer surface as distinct sulphur-yellow 
spots, or the nail may become dry, opaque, split, furrowed, fissured, raised from 
its bed, presenting a similar appearance of the nail, as in some other forms of 
onychitis, and indistinguishable except by a microscopic examination of scrap- 
ings from the diseased parts. 

Favus tends always to pursue a chronic course, beginning often in child- 
hood and lasting sometimes for years ; varying greatly in intensity in different 
cases, occasionally ceasing spontaneously, but sometimes becoming extensive 
and exhibiting all its various phases at one time, and finally, perhaps, losing 
all its earlier characteristics in indefinite scaling and atrophic scars here and 
there in the regions affected. 

On the non-hairy parts especially the disease is apt to assume atypical forms 
and resemble circinate ringworm; occurring in round, scaly patches which 
become clearer in the centre, forming an elevated ring, vesicular, papular, scaly 
or smooth. Two or more patches may unite into figurate patterns, and in the 
centre or near the circumference of the primary or secondary patches may be 
found the characteristic favus crusts. The latter may be absent, owing to the 
less favorable location for the fungus to flourish in the lanugo follicle than in 
the follicle of the larger hair of the scalp ; for the same reason the disease is 
more apt to cease spontaneously after, perhaps, a more rapid development, and 
to leave less marked or no atrophic effects behind. Sometimes, however, it 
exhibits the same vigor and persistence on the non-hairy parts as on the scalp, 
and the neglected cases may extend over a large part of the skin. The most 
frequent complications of favus are pediculosis, impetigo contagiosa, eczema 
and enlargement, rarely suppuration of the cervical glands. These affections 
not only change the objective features of the primary disease, but may con- 
tribute largely to the sensations of itching, tension, fullness, which in uncom- 
plicated favus are usually very slight. In a well-developed case the odor of 
favus is characteristic, and has been likened to musty straw or mice. 

Etiology and Pathology. — While favus is directly contagious from one 
person to another, from animal to animal, mice, cats, dogs, rabbits, fowls, and 
from the latter to man ; it develops so slowly and then only when undisturbed 
for a time that it is rarely communicated to a well-cared-for skin. Filth and 
personal uncleanliness are almost essential co-operating factors in the mode 
of contagion. It does not spread in a family or institution with nearly the 




Fig. 82— FAVUS 

ISOLATED PATCH OF THE FOREARM 

Patient is a girl of twelve, well nourished but uncleanly. Disease began twenty 
days ago, and has been attended with itching sensations just about the crusts, 
where the effects of scratching appear. The lesion consists of one whole and a por- 
tion of another favus cup situated on an irregularly reddened area. Cured in a week 
by daily cleansing with kitchen soap and water followed by applications of sulphur 
ointment. 




Fig 83.— FAVUS 

CHRONIC. GENERALIZED VARIETY OF THE SCALP 

Patient is a young, undersized and rather anaemic boy. Disease first appeared 
about two years ago in multiple scaly points from which developed yellowish cup- 
shaped crusts. The latter have been less and less apparent as the course lengthened, 
while the scaliness became more diffused. Under phosphorus sixth decimal, inter- 
nally and the application of a fifteen per cent, oleate of copper ointment daily to 
the scalp great improvement occurred. 



FAVUS 299 

readiness of ringworm or scabies. But once well established in the skin the 
fungus of favus multiplies with greater luxuriance than any other vegetable 
parasite. Favus appears to be a disease of the country districts, while ring- 
worm is more common in cities; further, favus may be said to be much more 
frequent in public practice than in private work. 

This fungus was first discovered by Sehonlein in 1839, and has since been 
known as the achorion Schonleinii. It consists of mycelium and spores, the 
latter often found in chains. The spores usually gain access to the skin 
through the hair follicle, and there in a measure protected, find space to 
develop, infiltrating the corneous layer of the epidermis and deeper cells 
of, the hair follicle with mycelium and spores. Their growth between the 
layers of the epidermic cells lifts up the outer layers around the hair 




Fig. 84. — Favus fungus — achorion Schonleinii (x about 800; diagrammatic . 

shaft, most at the periphery where there is the least resistance, and less 
nearest the hair where the epidermis is more fixed, thus producing the 
favus crust with its elevated border and cup-shaped centre. With the 
fungi between the corneous cells are found bacteria and drops of fat which 
contribute to form the bulk of the favus lesion. The counter pressure 
inwards on the cells of the rete due to the resistance of the outer layers 
compresses the former, and if long continued may lead to atrophy or inflam- 
mation, with resulting scars before mentioned. When, however, the fungi 
invade the cutis by a downward growth of mycelium between the fasciculi, 
the subsequent cicatrices may be due to the reaction process set up by the inva- 
sion creating inflammation, exudation and final absorption of the affected con- 



300 FAVUS 

uective tissue. Scars of this origin are likely to be permanent. It is believed 
that the fungus finds its way into the hair chiefly through the more vulnerable 
cells about the bulb, and to some extent through the cortex. They are often 
found abundantly in both the root and root sheaths, running principally in 
a longitudinal direction, and between the two causing separation and loosen- 
ing of the hair. From the root the parasite may penetrate into the subcu- 
taneous tissues, giving rise to inflammation and consequent scarring. 

For microscopic examination a hair may be extracted, soaked in a five 
per cent, solution of caustic potash and then slightly flattened out on the glass 
slide. A particle of favus crust may be prepared for examination by first 
macerating it in a solution of ammonia, which isolates the parasitic fungi. 
The. spores are about l-3000t.li of an inch, and the mycelium filament smaller in 
diameter. A magnifying power of 300 to 500 brings them in plain view. They 
may be stained a brownish color by moistening them with a few drops of an 
aqueous iodine solution to which has been added iodide of potassium. 

Diagnosis. — A typical case of favus may be recognized without difficulty. 
The sulphur-yellow, cup-shaped crusts are pathognomonic, especially on the 
scalp with the central penetrating hair ; the friable nature of the crusts and the 
mousey odor are diagnostic. When all the crusts have lost their typical shape 
and color, the disease is liable to be mistaken for crusting or scaling eczema, 
psoriasis, seborrhcea and ringworm. 

Eczema occurs in diffused, ill-defined patches; its crusts are greenish-yellow 
or darker, tenacious, not powdery, without characteristic odor; the hair remains 
unaffected or matted together; it may be thinned but does not fall out in 
isolated patches, and there is no scarring as compared with the well-defined 
lesions of favus, its sulphur-yellow, dry, friable crusts, characteristic odor, 
dry, lustreless hair, easily falling out in the affected patches, and often resulting 
in scars. In psoriasis the scales are whiter and cover a smooth, reddish surface, 
which easily bleeds; the hair is unaffected and there is an absence of odor or 
scarring. While nearly always some sulphur or lemon-yellow scales can be 
found at the border of a patch or about a hair in favus. the surface is apt to 
be depressed underneath, the hair is always affected, and there may be odor 
and scarring. 

Seborrhcea of the scalp is usually diffused, not sharply defined, the scales 
are fatty and the skin underneath is smooth, normal or paler in color; any 
loss of hair would be a general thinning and scarring would not occur. These 
differences would easily exclude favus. A circular patch of seborrheic derma- 
titis of the non-hairy parts might be confounded with favus before the appear- 
ance of the yellow cup-like crusts of the latter. The presence of seborrhcea 
of the scalp, the deeper redness of the patch, and the greasy scales would favor 
seborrhcea. In differentiating any of the above diseases a microscopical dis- 
covery of the favus fungi would be conclusive. 

Ringworm and favus patches may closely resemble each other and even 
the microscope may not give a positive differentiation. A more uniform scali- 
ness of the patch, the vesicular, advancing border and the stubbly hairs favor 



FAVUS 801 

ringworm. Under the microscope the spores of ringworm are found to be 

smaller, more uniform in size and less numerous than those in faros. The--; 
in connection with the microscopic features will usually Berve to distinguish 
tricophytosis. If not, a few days without treatment may show a development 
of t'avus crusts or new foci of ringworm as the case may be, though n must 
be said the distinction is not very important. 

Prognosis. — This is almost invariably good under persistent treatment. 
and the general health is commonly unaffected Kaposi mentions one ease 
of general i'avus attended with intense dermatitis, vomiting and diarrhoea, 
which proved fatal, and on post mortem revealed favus foci in the mucous 
membrane of the oesophagus. 

Treatment. — Methods directed to the removal of the efficient cause are 
first and always in order in the treatment of I'avus. The crusts may he ali- 
ened with applications of oil tor a few hours, a cap or hood being constantly 
worn over the head; then the larger crusts can be lifted oil' and the remnants 
removed by thorough cleansing with soft soap and water. This will he facili- 
tated by first cutting the hair short, as will also the application of a parasiti- 
cide to follow. Choice of the latter may he somewhat guided by the extent of 
the disease and the surroundings of the patient. In public practice, when the 
patient is not under close observation, a saturated solution of sodium hypo- 
sulphite is safe and efficient and can he applied freely with friction twice daily. 
A saturated solution of sulphurous acid, or a one to four per cent, solution of 
formalin used in the same way is highly recommended. Sulphur ointment, in 
the strength of two drachms to an ounce of lard, may he entrusted to the 
same class of patients. In obstinate cases an ointment of oleate of copper, one 
to three drachms to the ounce, has been found serviceable. More cleanly and 
nearly as effective applications are naphthot, one part. to eight of ointment 
base, or resorcin, one part to three of lanolin and five of sweet almond oil. 
Solutions of bichloride of mercury (two grains to the ounce of ether or alcohol) , 
and other preparations of mercury are sometimes advised in the local treat- 
ment of favus, but they are ill adapted for use on the skin of children, and pos- 
sess no advantages over less objectionable parasiticides. Whatever application 
is employed, the diseased hairs should be extracted so far as possible just pre- 
vious to its use; thus permitting the medicament to enter the follicles left open 
by their extraction. Various methods of epilation are practiced : Kaposi advises 
grasping the hairs between the thumb and a blunt tongued spatula held in 
the hand. With moderate traction the affected and loosened hairs come out, 
while the sound hairs remain in place. I have found a worn (roughened) 
kid glove finger cut from an old glove, and which fits closely on the 
finger, a good' substitute for the spatula or piece of cardboard sometimes 
advised. With it epilation can be done more rapidly, painlessly and just 
as effectively. The diseased hairs should he extracted daily as long as found 
in any number, and occasionally thereafter until a cure is effected, which usu- 
ally requires several months. The painful method of epilation practiced by the 
French through application of the pitch cap. which, on removal, brought away 



302 TINEA TRICHOPHYTINA 

the sound as well as the diseased hairs, is not advised, while the method of 
Bulkley, though a great improvement over the French "calotte," and less 
painful, is not as convenient as, nor more effective than the first-named plan. 
Bulkley uses compound pitch sticks, which are heated, entangled in the hair 
of the diseased area and when cool are quickly withdrawn, bringing the hair 
with them. The formula from which these sticks are made is as follows : 

R. Cerse flavae 5 3. 

Laecse in tubulis 5 4. 

Resinse 5 6. 

Picis Burgundies 5 11- 

Gummi dammar a 1J. M. 

The Rontgen rays have been used to remove the hair and the danger of 
permanent alopecia is slight, but as a rule the disease will reappear with the 
new^growth of hair. 

Epilation forceps can be used in removing the affected hairs, especially the 
very short ones. When there are only a few short hairs left on a patch I have 
found painting the surface freely with strong iodine tincture, and as soon as 
dry covering it with a coating of collodion, to work well. This, in a degree, 
occludes the air from the affected part, and any remaining stumps of diseased 
hair are likely to come away when the collodion film is removed with forceps 
after two or three days. The dressing can be repeated as many times as needed, 
care being taken not to excite a dermatitis. Favus of the general surface is 
easily cured. After removal of the crusts thorough washing with strong soap 
may be sufficient, but it is wiser to rub in some one of the parasiticides above 
named. 

When the nails are affected the diseased spots should be scraped thin re- 
peatedly, and a strong antiparasitic ointment rubbed in twice daily, or a mer- 
curial, hydronaphthol or resorcin plaster may be worn on the nails during the 
night, or continuously in some cases. Avulsion is sometimes recommended as 
the quickest method of cure ; it is seldom necessary. 

All cases probably recover faster under the tissue effect of an internal 
remedy combined with the causal methods outlined. See Kali carb., Lye, Mcz.. 
Nat. mur., Plios., Staph, and Sulplivr. 



TINEA TRICHOPHYTINA 

(Trichophytosis; Ringworm.) 

The regional varieties of ringworm were once thought to be distinct diseases, 
and although all are now known to be due to the presence of one of the ring- 
worm fungi, their clinical differences make it convenient to retain the distinct- 
ive or qualifying names. There are three principal forms: tinea circinata 
(ringworm of the body) ; tinea tonsurans (ringworm of the head) ; tinea 
barbae (ringworm of the beard). While two others, tinea cruris seu axillaris 




Fig. 85.— TINEA CIRCINATA 

CIRCINATE VARIETY OF THE LIPS 

Patient is a boy twelve years of age, with a scrofulous type of skin and feature.-, 
though reported to be in good health. Disease began eight weeks ago, while attend- 
ing school, as a reddish, scaly, well-defined pea-sized spot just below the lower lip. 
As the lesion cleared in the centre it extended at the periphery below the mouth by 
a slowly advancing row of elevated scaly papules; crossed the mouth and invaded 
the upper lip in the form of an erythematous scaly line. Cured with baryta carb., 
sixth decimal. 





•»' ': 






^^^B| . •• 






JL v ■ ^.L^jHSe 






^^^^^B 




• % 


*%B 





Fig. 86.— TINEA TONSURANS 



Patient, a girl of twelve. History of direct contagion. For two months treat- 
ment was neglected and the patch became eczematous. A smaller lesion at the 
outer angle of the left eye developed secondarily and retained the typical appearance. 
Cured by a solution of ten per cent, of tincture of iodine in collodion, which was applied 
four times at intervals of three days. The small patch disappeared after the first 
treatment. 



TINEA TRICH0PHYT1N A B08 

(eczema marginatum), and tinea nnguim (ringworm of the nails), may l>o 
looked upon as subordinate forms. 

Tinea circinata. — (Trichophytosis corporis; Herpes circinatus; Ringworm 
of the body.) Ringworm of the body may appear alone or in association with 
other forms of the disease. It begins as a small pale-red, well-defined and 
slightly raised spot, which soon becomes scaly, tends to clear in the centre as the 
periphery extends, thus forming a ring-like lesion. The border is pretty uni- 
formly elevated during its further development, sharply defined, and often 
consists of papules, papulo-vesicles as well as small scales. Either form of 
lesion may predominate at the periphery. A patch may reach the size of a 
nickel to the palm of the hand before completing its evolution, then remain 
stationary for a time, or involution may at once begin, resulting in its gradu- 
ally disappearing spontaneously. Sometimes gyrate forms may result from a 
coalescence of neighboring rings. Quite often the lesions are single or on differ- 
ent parts of the body; more frequently there are several in the same region, 
usually on the exposed surfaces, such as the neck, face, hands, etc. Any 
part of the body may be attacked, but generally without symmetry or order. 

When the disease attacks the skin of the crural or axillary regions, however, 
or in so-called eczema marginatum, symmetry of development is often ob- 
served. Here the warmth and moisture of the parts greatly favor the growth 
of the fungus, and the rapid development of the lesions excites great itching, 
irritation, and sometimes inflammation. Starting about the inner part of 
the thighs or inguinal regions, single or conjoint patches extend rapidly, coal- 
esce and form festooned, elevated, broad, papular, squamous borders enclosing 
inflamed or pigmented areas. jSTot infrequently fresh rings or segments of 
circles form within the enclosure, while the primary line may keep on advanc- 
ing even down to the knee, up to the navel, or on to the perineum and out 
over the buttocks. There is commonly more or less eczematous inflammation, 
and in some cases considerable exudation and crusting. Rarely the disease 
is exhibited at first in distinct, elevated lines, concentric rings, circles, broken 
circles, or festooned loops, with the skin comparatively clear between. In 
tropical climates this variety occurs in such aggravated forms that the name 
of the country is sometimes given to it, as, for instance. Chinese or Burmese 
ringworm. 

Tinea circinata patches frequently do not clear in the centre, but remain 
scaly with or without the papular or vesicular border; the latter may be little 
raised though well defined and the patch may be irregular in shape. Again, 
the border may be pustular from more intense inflammation, or the whole of 
the affected surface may exhibit scattered papules, vesicles or pustules. Unless 
more typical ringworm lesions are found, these variations could hardly be 
recognized except by microscopic tests. 

The nails are not often attacked by the ringworm fungus, tinea vnguim or 
onychomycosis. Under the latter term it will be found in the section on 
diseases of the nails, and its treatment will be referred to later. 

Tinea tonsurans. — (Trichophytosis capitis; Herpes tonsurans; Porri^o 



304 TINEA TRICHOPHYTINA 

furfurans; Tinea tondens; Bingworm of the scalp, etc.) Kingworm of the 
head is a common disease among neglected children. It begins as a super- 
ficial affection of the scalp in the form of a scaly, reddish, round or irregular 
patch. This is small at first, and if seen early enough may appear as a papular 
elevation about one or more hairs; it soon enlarges, with perhaps a show of 
vesicles or pustules at the margin, which do not long persist as a rule, and the 
whole surface of the patch is found covered with whitish, branny scales; 
continuing to spread at the periphery, it may reach the size of a dime to a 
silver dollar. In the meantime the disease extends to the hairs; they lose 
their lustre, become dry, brittle and broken off. or on any attempt to remove 
them break near or below the surface. Sometimes the hairy stumps are so 
short that careful search is necessary to find them, and in fair, fine-haired 
persons the hairs may be twisted or matted down with the scales. A round, 
ringworm lesion of the scalp may look like a priest's tonsure, hence the name, 
tinerrionsurans. Other patches usually exist on some parts of the scalp, and 
two or more may coalesce and form irregular or gyrate shapes of large extent. 
The favorite sites are the crown and parietal regions. Tinea circinata may be 
present at the same time on the adjacent regions of the neck or face, or on 
more remote regions of the body. 

The color of the larger patches of trichophytosis capitis varies somewhat 
in different cases; more often they are a dirty gray shade, but they may be 
a bluish-gray, greenish-yellow, or keep their earlier reddish hue. They are 
elevated above the surface and sharply defined. The ends of the broken hairs 
often have a whitish look from the presence of the fungus and epithelial 
debris. In the further course of the disease the hair may fall out spontaneously 
and temporary baldness result. As the scales desquamate or are removed the 
follicles may have a puckered appearance, which has been compared to the 
skin of a feather-picked fowl, and occasionally a few pustules may be found in 
connection with the remnants of diseased hair stumps. When the pustular 
inflammation is deep in the follicle the condition known as Jcerion exists. 

Kerion, or pustular folliciditis, due to the invasion of the ringworm fungus, 
and probably also to pus cocci or other organisms, is therefore theoretically 
a product of a mixed infection analogous to the process in tinea barba?. It 
develops by an aggregation of inflamed follicles into cedematous or fluctuating, 
well-defined elevation of the scalp, yellowish, reddish or purplish in color and 
at the outlets of the follicles studded with siippurating points. The hair is 
loosened by the suppuration and falls out, giving exit to a muco-purulent. 
honey-like discharge. These lesions often resemble carbuncles, but are not 
as painful or prostrating, and do not result in sloughing, though abscesses 
sometimes form. Kerion may be mild or severe : it tends to pursue a persistent. 
chronic course and the presence of the parasitic fungiis cannot always be 
demonstrated. Permanent baldness may follow the severe cases. Sometimes 
impetigo contagiosa becomes a complication of tinea tonsurans and both 
diseases may spread rapidly in consequence, but the superficial character of 
the impetigo lesions readily distinguishes it from kerion. 




Fig. 87— TINEA TONSURANS 



Patient, a Jewish girl of ten. Duration of disease, one year. The 
trichophyton fungi were easily found microscopically. Treatment con- 
sisted of frequent applications of a five per cent, solution of iodine in col- 
lodion and the use of baryta carb., sixth decimal, internally. A cure was 
effected in two months. 



TINEA TRICHOPHYTINA 

Occasionally ringworm persists on the scalp in a disseminated form, in 

which there is little or no loss of hair or other special signs of the di 
excepi sonic scaiiness and on careful search a few dry, brittle bairs or one 
or more broken stumps of hair scattered here or there. In young children 
or youths with fine hair, superficial circinate lesions may occasionally be 
seen, which may later assume the features of ordinary cases or disappear quickly 
under treatment. Another rare variation has been described as bald tinea ton- 
surans which, often beginning as ordinary ringworm, is succeeded by a cir- 
cumscribed baldness and a smooth appearance of the patch similar to alopecia 
areata. Usually stumps of hairs may be found around the border of the area 
denuded of hair, and the ringworm fungus may be found in the affected 
hairs. Some authors believe that this form is closely related to the para- 
sitic variety of alopecia areata. Most forms of ringworm of the head are 
unattended with pain, but some degree of itching is commonly felt. 

It is possible in some cases to differentiate clinically the ringworms caused 
by the trichophyton as contrasted with those cases caused by the microsporon 
Audouini, but the value of such distinction is slight to the physician, whose 
aim is solely to cure the disease. 

Tinea barbae. — (Trichophytosis barbae; Tinea sycosis; Sycosis parasitica; 
Parasitic sycosis; Herpes tonsurans barbae; Mentagra parasitica; Eingworm 
of the beard; Barber's itch, etc.) Eingworm of the bearded portion of the face 
and neck of the adult male usually begins as a tinea circinata, and may run 
a superficial course, and ending in favorable cases without inflammation of 
the hair follicles. "When the latter are involved the hair becomes dry. brittle, 
often whitish in color, is easily removed or falls out. Papules develop on the 
surface, and deeper, nodular, tender indurations form, varying in size and 
shape and covered by the elevated, red or purplish skin. Hair pierced pustules 
may be present in a few or large numbers, and in the more cleanly victims of 
barber's itch these may chiefly characterize the disease; in other cases there 
may be considerable surface suppuration forming crusts as in pustular eczema, 
which, on removal, may reveal the syeotic (fig-like) appearance of the inflamed 
skin. Not infrequently suppuration is absent or very slight ; in fact, the disease 
varies widely in degree and extent, sometimes the pustular, the nodular or the 
eczematous form predominating, or again mingling together. The disease may 
occur on any part of the bearded portion of the face, and on one or both 
sides. More commonly it is found on or near the chin and neck. The local 
sensations felt are varying degrees of itching, burning and tension. 

This variety of ringworm always tends to pursue a chronic course. Lasting 
frequently for years, and often relapsing if not persistently treated. Tin 1 pro- 
cess in the nodular type is analogous to kerion of the scalp, due to the penet ra- 
tion of the fungus element through the hair follicle into the root and shaft o( 
the hair, and by its presence and growth separating the latter from its follicle 
and producing more or less infiltration and inflammation of the adjacent tissues. 
If the suppurative process destroys the follicles, permanent lose of hair and 
scarring result. 



306 TINEA TRICHOPHYTINA 

Etiology and Pathology of Eingwoem. — All forms of trichophytosis 
are highly contagious, either direct, from one person to another, or through the 
medium of clothing, hats, caps, combs, brushes, towels and, in tinea barbae, 
through other utensils used in shaving, such as brush, razor or strop. Where 
many children are congregated it is possible that the parasitic fungus may be 
conveyed through the air. Animals subject to the disease, the cow, horse, dog 
or cat, may transmit it to man, and, vice versa, man may inoculate animals. 
It is probable that a certain susceptibility of the surface tissues pre-exists in 
many individuals attacked with ringworm, but to what it owes its existence is 
uncertain, as it occurs in the well about as often as in the poorly nourished, 
and in relative proportion to exposures probably as frequent in the well-to-do 
as in the needy. Age exerts an influence, in that tinea tonsurans is almost 
exclusively an affection of childhood ; as a rule, it is more amenable to treatment 




Fig. 88. — Trichophyton fungus (x about 600; diagrammatic). 

with the approach of puberty, and rarely originates after that period; tinea 
circinata may occur at any age, but is rare after middle life, while tinea 
barbae is a disease of manhood and most common in the early half of adult life. 
Sabouraud's investigations, which are generally accepted, make two chief 
divisions of the ringworm fungus, microsporon Audouini or small-spored fun- 
gus, and the trichophyton or large-spored fungus. The former appears micro- 
scopically in the form of round spores massed about the follicular portion of 
the hair and mycelial threads which are seen chiefly within the hair. The visi- 
ble white or gray coating of the hair seen above its exit from the follicle is due 
to a sheath of spores surrounding the shaft. While the mycelia in this fungus 
are within the hair proper, at their terminations will be found spores which 
are external. In France the microsporon is rarely found in kerion, but is 
responsible for sixty per cent, of all cases of ringworm of the scalp in chil- 



TINEA TRICHOPHYTINA ;;,( ' 

dren. If found in ringworm of the body or beard, the patches are not typical 
and rarely persist. The trichophyton is composed of cuboidal or oval spi 
larger than those of the microsporon and arranged in chains or lines extending 
up and down the hair shaft. The mycelia are found without the hairs and 
never within, while the spores vary in location. Three forms of trichophyton 
may be noted: endothrix, in which the spores occur wholly within the hair and 
which is found, like the microsporon, chiefly in ringworm of the scalp of chil- 
dren, although it may occur in atypical lesions on the face and neck ; ectothrix, 
in which the spores are found wholly without, and endo-ectothrix, in which the 
spores are found both within and without the hair. The last two varieties of 
trichophyton are derived from domestic animals, directly or indirectly, and 
cause ringworm of the beard, of the body and of all pustular or suppurating 
varieties. Some authorities prefer to believe that the varied appearances of 
ringworm lesions are due wholly to differences in the media or in the cultiva- 
tion of the parasite. The geographical distribution of the varieties is interest- 
ing. In London ninety per cent., in Paris, sixty per cent, of all cases of tinea 
tonsurans in children are due to the microsporon, and White of Boston found 
it in 139 out of 279 cases examined. In England the microsporon even occurs 
in ringworm of the body and in kerion; on the other hand, it is unknown in 
parts of Italy and Germany ; while the trichophyton is rare in England. 

For microscopic examination the scales removed from a supposed ring- 
worm lesion should be placed on a glass slide, moistened with a drop or two of 
liquor potassae, over which a glass cover is firmly pressed to separate the parti- 
cles underneath. If a hair root is to be examined, it should be soaked first 
for half an hour in the potash solution and then flattened out under the glass 
cover. Under a power of at least two hundred and fifty diameters the conidia 
or spores and mycelium threads can be usually found, if the scales or hair 
were obtained from a true case of ringworm. A higher power may be needed 
to bring the fungus elements into clear view in some cases, but the absence of 
fungi is not always proof positive of the non-existence of trichophytosis. The 
microscopic evidence may not be easy to find. 

In tinea circinata the fungus is situated in and under the corneous layer 
of the epidermis, giving rise to papules, vesicles and desquamation. In the 
tinea tonsurans and tinea sycosis, it usually invades both the epidermis and the 
hair follicles. The growth of the parasites in the hair is much more vigorous 
than in the superficial layer of the skin, though found, as a rule, most abundant 
in the corneous layer about the hairs when the latter are affected. The spores 
are found to greatly exceed the mycelium in ringworm of the head, while it 
is claimed by Jamieson that in ringworm of the beard the mycelium are 
most numerous, and account for the more intense grade of inflammation com- 
mon in the latter form, the growth of mycelium proving more irritating than 
the multiplication of spores. The fungus gains access to the hair through 
the follicle, between it and the hair shaft, and working downwards it reaches 
the soft substance of the bulb. Here the spores have been found in large 
number previous to the invasion of the shaft, which supports the general belief 



308 TINEA TRICHOPHYTINA 

that the hair shaft becomes affected from the bulb upwards, though Unna 
and others hold the opinion that the fungus penetrates from the more super- 
ficial portion of the follicle directly into the shaft of the hair through its cuti- 
cle. By whatever avenue of ingress the conidia reach the bulb of the root in 
their subsequent growth upwards, the fibres of the cuticle and also the epidermic 
laminae of the shaft become separated to some extent, rendering the hair brittle 
and easily broken. Besides invading the hair and inner root sheath, according 
to Bobinson, the fungus may penetrate into the outer root sheath, and in severe 
cases into the perifollicular tissue. 

Diagnosis. — This is very important, particularly when the disease arises 
in a family of children or in institutions for the care of children where, if 
unrecognized, it is likely to be soon spread from child to child. Typical cases 
of ringworm of the body are often distinguished by the laity by the circular and 
ring-like patches. On the scalp dry. scaly patches in which the hair is broken, 
twisted in various directions, or in fine-haired children sometimes matted or 
entangled with the scales, is always an indication of tinea tonsurans. Duck- 
worth's simple test will help to determine the diagnosis. It consists in placing 
a few drops of chloroform on a suspected patch and allowing it to evaporate; 
the hairs affected with fungus turn yellow or white, whereas the sound hairs 
are not affeeted.- 

The disease in either form may, however, simulate eczema, psoriasis, sebor- 
rhcea, favus, pityriasis rosea and alopecia areata. 

Squamous eczema patches are not so sharply defined as those of ringworm, 
do not spread by an elevated and advancing border, but rather merge gradually 
into the surrounding skin with more even distribution, greater infiltration, 
and without healthy areas of skin between neighboring patches. On the scalp 
the hairs are not affected by eczema, nor do the patches extend by peripheral 
growth as in ringworm. Moreover, squamous eczema is non-contagious, chronic 
in course, attended with a greater degree of itching, and the fungus is absent. 
Occasional^ the two affections may coexist, and rarely the itching in tinea 
tonsurans may be intense enough to lead to excoriations like those common in 
eczema. 

Psoriasis of the scalp or the non-hairy surface may develop by peripheral 
growth into similar shaped scaly lesions as ringworm, but as a rule the lesions 
of the former are more numerous, symmetrically distributed and chiefly on 
the extensor surfaces, and the scales are thicker, pearly-white and more abun- 
dant. On the scalp the hairs are unaffected as in tinea tonsurans. Further- 
more, in psoriasis there is no history of contagion, its course is generally chronic, 
and the parasitic fungus is absent. ■ 

Seborrltoea or seborrhceic dermatitis may develop in well-defined round, cir- 
cular or annular patches resembling tinea circinata; but the scales of sebor- 
rhcea are somewhat greasy, and the open orifice of the follicles can usually be 
seen. Seborrhcea of the scalp is commonly diffused and symmetrical as com- 
pared with the usually circumscribed and asymmetrical patches of ring-worm. 
The latter is a disease of childhood, whereas seborrhcea is commonlv an affee- 



TINEA TRICHOPHYTINA ; ' ,,; ' 

tion of adult life, and if the hail is affected it is by a general thinning instead of 
by the characteristic broken-oft' stumps due to ringworm. In all doubtful cai 
the microscope should he employed to determine the presence or not of the 
fungus in the scales or hair. 

Favus is ordinarily easily distinguished from ringworm by its peculiar cup- 
shaped crusts and odor. For other differential points see the former. 

In pityriasis rosea the lesions are more widely distributed than those of 
ringworm of the body; they are usually most abundant on or limited to the 
trunk, rose-red or yellowish in color. It is less scaly, not contagious, or due 
to the presence of fungi, and generally disappears spontaneously in from 
two to eight weeks. 

A case of "bald tinea tonsurans" may closely resemble parasitic alopecia 
areata, if not identical with it. The presence of other ringworm lesions on 
the same patient or in other members of a household, school, or the detection 
of the fungus in the diseased hairs at the margin of a patch are the only 
certain ways of diagnosis. 

When kerion develops on the scalp it may present a likeness to carbuncle. 
The different history, absence of necrosis, and the possible discovery of the 
parasite on or after repeated microscopic examination will distinguish kerion. 
Superficial ringworm of the beard may be recognized by the same diagnostic 
features as pertain to tinea circinata, and may be differentiated thereby from 
the same affections as the latter. When the hair follicles become invaded, 
tinea barb* may be mistaken for ordinary (coccogenous) sycosis, or for eczema 
of the beard. Pustular sycosis begins with the formation of pustules at the 
mouth of the follicles with a firmly implanted hair piercing the centre of each ; 
free suppuration may occur, but is generally superficial, and extraction of 
the hair is painful; while tinea sycosis penetrates to the deeper parts, pro- 
ducing lumpy or brawny swellings with little or no suppuration, but with 
loosening of the hairs involved which may be extracted easily and without 
pain. Pustular sycosis is attended with pain, burning or itching, is much 
more common, often affects the upper lip, where tinea sycosis seldom occurs, 
and the latter rarely causes much suffering. Finally a microscopic examina- 
tion of the diseased hair will reveal the fungus in a case of ringworm sycosis. 

Eczema of the bearded portion of the face or neck may not be limited to 
the follicles (eczematous folliculitis), but also involve the inter-pilary sur- 
faces with serous or sero-purulent discharge, crusting, etc., common to the 
eczematous process, and not occurring in uncomplicated tinea sycosis. More- 
over, the nodular or lumpy swelling is absent in eczema, the hairs remain unaf- 
fected and cannot be extracted without difficulty and pain. 

Prognosis. — Tinea circinata is easily cured in from one to two weeks. 
Tinea tonsurans and tinea barbae are always curable under judicious and 
persistent treatment, but it is very difficult to foresee how much time may be 
required to effect a cure; probably four or five weeks to as many months would 
represent the extremes. 

Treatment of Ringworm. — As there is no doubt as to the efficient cause 



310 TINEA TRICHOPHYTINA 

of ringworm, so there can be no question as to the wisdom of employing means 
to effect a removal of the prime factor. It is quite true that the disease on the 
non-hairy parts of the skin can be cured by indicated drugs, but such treatment 
alone lacks the element of prevention so important in the management of 
parasitic disease. On the hairy surfaces both local and internal medication 
are often needed to effect a satisfactory cure, only obtained in obstinate cases 
after long and persistent treatment. In all cases the clothing worn next to 
the skin, hats, caps, toilet articles, etc., in use should be disinfected or steril- 
ized by baking or boiling. 

Tinea circinata may be treated locally with almost any simple parasiti- 
cide after the skin has been thoroughly softened and cleansed with soap and 
water or alcohol. Painting the patches with tincture of iodine, or twenty-five 
per cent, solution of iodine in collodion, daily for five or ten days is often 
effective. Boric acid, one drachm, thymol, ten drops, to three ounces of alcohol, 
is suited to mild cases. Hyposulphite of soda in saturated aqueous solution, or 
sulphurous acid solution, and for adults a solution of corrosive sublimate in the 
strength of two to four grains to the ounce of water may be used for severer 
cases. Any of the following ointments are usually efficacious: Salicylic acid, 
twenty to fifty grains, sulphur sub., one to two drachms, or hydrarg. ammon., 
ten to forty grains to an ounce of lard or simple cerate, and ung. hydg. nit. dil. 
The two last are well adapted for application to the affected skin of infants or 
younger children. The younger the child, as a rule, the less strength of para- 
siticide required. Ointments or washes should be applied three times dailv 
for a few days, and then less frequently for a longer time. In the form of 
trichophytosis known as eczema marginatum, the strength of the local applica- 
tion should be adapted to the needs of each case. Any of the parasiticides men- 
tioned above may be used, but frequently owing to the luxuriant growth of the 
fungus in this variety stronger applications are needed. In obstinate cases 
I have found nothing superior to oleate of copper ointment diluted one-half 
with vaseline or lard. When there is considerable congestion and sensitiveness 
of the parts the following combination recommended by Shoemaker has been 
found serviceable : 

1$. Acidi carbolici gr. 5. 

Cupri oliatis gr. 10. 

Ungt. zinei oxidi benz 5 1. 

M. Sig. — Apply thoroughly night and morning. 

Whatever ointment is used closely fitting cotton trunks may be constantly 
worn, or when the disease is in the axillary region a closely worn undershirt is 
helpful in keeping opposing surfaces apart and protecting the outer clothing 
from the medicament. For the latter purpose thin rubber or oil silk can be 
stitched over the inner garment. If for any reason ointments are objectionable, 
the sodium hyposulphite solution can be used or mercur. cor. one to three grains 
to an ounce of tincture of tolu. The latter can also be painted over the part 
every day or two for one or two weeks following an apparent cure to prevent 
a relapse. 



TINEA TBICHOPHYTINA :; 1 I 

Onychomycosis or ringworm of the nails may be treated by thoroughly 
scraping the diseased parts of the nail, followed by covering the nail with lint 
soaked with the sodium hyposulphite or sulpliurous acid solution before men- 
tioned, covered with a thin rubber cap or glove, and worn during the night. If 
the hands need to be used during the day, the nails may be covered with mercu- 
rial plaster and overlaid by a longer piece of thin adhesive plaster, or rubber 
finger covers can be worn. This plan may be repeated every day until evidences 
of the parasitic disease have disappeared, and then it may be followed by light 
applications once or twice daily of oleate of mercury ointment until the nail 
has regrown. In severe cases after filing or scraping the nail the latter ointment 
may be applied continuously until the diseased part exfoliates, or the plan 
mentioned by Crocker and credited to Harrison may be carefully tried. This 
consists in first scraping the nail and applying on lint under oil silk a solution 
(jSTo. 1) of liquor potasses and aq. distil., each half an ounce, and potass, iodid., 
thirty grains, to the diseased part for fifteen minutes; it is then removed and 
immediately followed by dressing the parts in the same manner with a solution 
(No. 2) of hydrarg. perchlor., four grains, spir. vini. red., and aq. dktil., each 
half an ounce, which is to be worn for twenty-four hours. The whole process 
is to be repeated until a cure is effected. When the adjacent skin peels and the 
parts become tender, the hyposulphite of soda solution may be substituted for 
the former method until the skin heals. The Rontgen rays, used carefully, 
have performed the same work as the last-mentioned elaborate treatment, in 
two cases of onychomycosis treated by the editor. 

Tinea tonsurans is by no means easy to cure, because an effective para- 
siticide cannot be made to penetrate readily into the deeper follicular recesses 
occupied by the parasite. Eelapses are common even after apparent cure; 
therefore treatment must be persevered with for a long time after diseased hairs 
or fungus elements cease to be found. When the disease is of short duration, 
superficial, or occurs in infants, the parasiticides suggested for tinea circinata 
may be employed. As a rule the hair should be cut short over and for about 
one inch around the affected area. The parts should be then thoroughly 
freed from scales by washing with soap and alcohol. I prefer salicylic acid 
soap and alcohol as the most effective in removing the scales and the outer 
corneous epithelia. Immediately following the cleansing and drying of the 
scalp, some antiparasitic should be well rubbed in or otherwise applied if not 
in ointment form; choice of strength and form of application should depend 
on the age of the patient, extent and intensity of the disease. The same may 
be said of epilation, as it is never free from pain, and, therefore, can seldom 
be practiced with young children. Neither is it as effective as in favus, because 
the brittleness of the hairs causes them to easily break off on traction, and yet 
in deep-seated ringworm of the scalp extraction of the diseased hairs promotes 
cure to a considerable degree. When epilation is deemed important the pre- 
vious use of oleate of copper (one part to eight of lard more or less, as found 
well borne) for a few days renders extraction much easier and less painful; 
in fact, the hair sometimes falls out spontaneously after the use of this para- 



312 TINEA TRICHOPHYTINA 

siticide. Its conspicuous color is about its only drawback, but as a cap lined 
with oiled paper should always be worn during treatment, this objection is 
largely met. The skin can be made less sensitive to hair extraction also by ap- 
plication of a solution of glycerine and carbolic acid ten to twenty-five per cent. 
Epilation forceps are most convenient for extraction of the hairs, which should 
be performed each day over a space of one-fourth inch to two inches according 
to the number of hairs or the endurance of the patient. The Rbntgen rays may 
be used to remove the hair, as suggested in the treatment of f avus. In older 
children or young people the plan recommended by Crocker will be found to 
possess several advantages, especially for circumscribed patches. The affected 
part and slightly beyond is first cleansed and shaved, and then the whole shaven 
surface is painted over with a ten per cent, salicylic acid collodion. The paint- 
ing is repeated daily for a week, when the accumulated cover of collodion is 
raised up at one side with forceps and carefully peeled off, bringing the 
attacheekhairs with it. The surface can be shaved again and the collodion 
applied for another week or ten days, and then removed as before. If any 
breaks are found in the surface of the epidermis thus uncovered, a mild para- 
siticide ointment should be applied for a few days until healing occurs, before 
resuming the painting with collodion. "While the removal of the latter is 
somewhat painful it is usually well borne, and by snipping off some apparently 
sound hairs attached to the collodion underneath as the latter is lifted off, this 
may be somewhat lessened. In cases to which this method is adapted it effec- 
tually renders the patch non-contagious by sealing it up, at the same time that 
it deprives the parasite of oxygen and moisture from the air on which it is 
in a measure dependent. It is also cleanly and requires the minimum of atten- 
tion in the interval between removals of the artificial crusts. Three series of 
renewals of this collodion, lasting six to ten days each, have proved efficient in 
my hands. Formalin, 1 to 1000 of water, or even a weaker solution, is some- 
times an efficient application in some cases, and has cured when kerion was 
present. For cases which cannot be looked after closely or in disseminated 
forms, especially in younger children, sulphur in a suitable form is a safe anti- 
parasitic. Its penetration may be facilitated by using lanolin and oil as a 
vehicle; sulphur sublimate, two to three drachms, to lanolin and olive oil, 
each half an ounce, is a usual combination. This should be well rubbed in 
twice daily. Carbolic acid is sometimes combined with sulphur in the pro- 
portion of half a drachm to the ounce of ointment. In disseminated varieties 
of tinea tonsurans or to apply to non-affected parts of the scalp as a preventive 
while other applications are made to the diseased areas, carbolic acid can be 
used once or twice daily in the proportion of thirty to forty drops to an 
ounce of glycerine. Boro-glyceride, fifty per cent, solution, or slightly more 
dilute, may be employed in the same way. Salicylic add. fifteen to twenty 
grains to the ounce, thymol, thirty to sixty grains to the ounce, or menthol in 
like proportions dissolved in either alcohol, ether or chloroform, or in equal 
parts of each, are efficient applications in the early or superficial stages of ring- 
worm of the scalp. When employed, cleansing with soap and water may be 



TINEA TR1C0PHYTINA 818 

omitted, and oily applications should no! be used al the same time. According 

to Malcolm Morris, the use of the spirit and ether solutions (particularly tin- 
salicylic) possesses several advantages: thej dissolve fatty matter, loosen the 
corneous epithelia and hairs, dehydrate the tissues and directl] attack the 
fungus. With one of the above solutions a quick cure may be often made of a 
superficial ringworm of the scalp, but they penetrate into the tissues to only 
a slight degree. The author has supplemented the use of a solution containing 
twenty grains of salicylic acid to an ounce of equal parts of alcohol and ether by 
painting the affected areas with tincture of iodine, applying vaseline to all 
portions of the scalp and covering all with two or three layers of glazed or oiled 
paper, something after the manner of Yidal. In the single trial of this method 
the result was a rapid cure. Theoretically, it meets most requirements of local 
antiparasitic treat meni : the Erst part of application perfectly cleans and de- 
hydrates the surface tissue, the second penetrates within, while the last, to- 
gether with the closely fitting paper, effectually excludes the air, with the 
further advantage that it can be freshly renewed each da}*, including new layers 
of impermeable paper. Vidal who emphasized the fact that the trichophyton 
fungus is aerobic, and that therefore exclusion of the air is an important aid 
in its destruction, first cleansed the scalp with turpentine (in place of the 
salicylic acid solution) before applying iodine, etc. The dressing was renewed 
twice daily, and he has reported very satisfactory results from his method. 

Mercurial preparations are sometimes advised for limited patches which 
tend to persist; of these the oleate of mercury is probably the best in five t" 
fifteen per cent, strength in lanolin oil, as it has good penetrating power. The 
bichloride in two to four grains to an ounce of lard, or in solution in water or 
alcohol, is said to be effective. Ointment of ammoniated mercury is better 
adapted for young children, but all mercurial preparations should be used with 
caution; and only on circumscribed areas, for fear of producing salivation. In 
fact, no application should be employed in too concentrated form at first. The 
scrofulous in particular are very susceptible to the irritating qualities of ex- 
ternal agents. In some of these lighter cases boric acid in ten per cent, ointment 
may be sufficient, and in more severe types of the disease a saturated solution 
of boric acid in twenty parts of alcohol to five parts of ether, as recommended 
by Cavafy, maybe applied three or four times daily, the scalp being thoroughly 
cleansed once a day with soap and hot water. If kerion exists it usually i 
only the milder applications. Crocker states that he removes the loose hairs 
and obtains uniformly good results from the following combination: Sulphur, 
two; carbolic acid, one; adipis, sixteen parts. From the apparent tendency 
of kerion to cure itself the production of artificial kerion with application-; of 
croton oil has been advised in obstinate cases, or when a more rapid cure is 
important. One part of croton oil to two to ten of olive oil applied to a small 
area of the scalp at a time produces in a day or two a pustular folliculitis with 
loosening of the hairs, which may be extracted, the surface cleansed and treated 
with boric acid or other mild antiparasitic ointment. Electrolysis may he used 
as an adjunct to this treatment. 



314 



TINEA TRICOPHYTINA 



There have been, numerous applications proposed and recommended for 
tinea tonsurans other than those mentioned. Of the latter those which have 
been verified by personal experience have been referred to more in detail. Cer- 
tain precautions should be taken in all cases unless an occlusion (collodion) 
dressing is employed; the head should be kept constantly covered with a cap 
or closely fitting hood lined with paper, which can be burned up and renewed 
each day. Soap and water should only be employed when needed for cleanli- 
ness, usually one to three times a week, and often alcohol or ether can be sub- 
stituted for water with advantage. The whole surface of the scalp may be 
treated with a mild parasiticide such as carbolized glycerine or boro-glyceride 
once a day to prevent new foci of infection, and for the same reason the hair 
should not be brushed, as thus the conidia might be spread about over the 
scalp. 

Sabouraud and Noire reported in 1904 upon their experiences with radio- 
therapy- as used in the Hospital St. Louis. Their formula is as follows : "To 
cure a patch of ringworm of the scalp by the X-ray, place the patch at a distance 
of fifteen centimetres from the centre of the focus tube, and place at the same 
time a dish of platino-cyanide of barium paper, eight centimetres from the 
centre of the tube. "When this disc has taken the color corresponding to the tint 
'B' of Sabouraud's radiometer, the operation is terminated." After the sev- 
enth daily treatment, slight erythema appears, which gives way to a faint pig- 
mentation. After two weeks' time the hair falls out and ointment of oil of 
cade is applied at night, followed by shampooing in the morning and the ap- 
plication of a weak solution of tincture of iodine. The great advantage that 
this method presents in institutional work is the economy of time. "Whereas, 
two years was formerly the average time of treatment, three months now 
suffices. 

Tinea barbae requires much the same method of treatment as tinea ton- 
surans, except the stronger applications are not commonly needed, and epila- 
tion is even more essential to a satisfactory result. Extraction of the loosened 
hairs is not painful, and should be done over a small area daily just before the 
application of an antiparasitic. Highly colored or disfiguring combinations 
should not be used upon the face unless the patient is in seclusion. Neither 
should poulticing or puncture of the lesions be practiced; the first stimulates 
the growth of the fungus, and the last is unnecessary, because extraction of the 
hair gives sufficient exit for the semi-fluid contents. The beard should be kept 
closely cut, crusts, if any, softened with applications of oil, and then the surface 
thoroughly cleansed with alcohol and soap, preferably the salicylic acid soap, 
which can be used on the non-affected region of the bearded part of the face as 
well as a preventive. Epilation having been performed over a square inch or 
more, choice may be made of one of the following for immediate application : 
A saturated solution of hyposulphite of soda; bichloride of mercury, two grains, 
to an ounce of cologne or alcohol, and half a drachm of glycerine; thymol, one, 
chloroform, three, and sweet oil five drachms; fifty per cent, boro-glyceride 
solution; resorcin or salicylic acid, grains forty to sixty, in lanolin and olive 




Fig. 89.— TINEA VERSICOLOR 

Patient is a middle-aged married woman in apparent health. Duration, nine 
years on the back, six months on the neck. The lesions consist of yellowish-brown 
macules partially covered with fine scales, which are made more apparent by fric- 
tion. Microscopic examination of the scales revealed the presence of the character- 
istic fungus. Cured in ten days by friction twice daily with a saturated solution of 
hyposulphite of soda. 



TINEA VERSICOLOR 815 

oil, each hali an ounce. Thoroughly applied night and morning the outward 
part of the disease is speedily improved^ hut long pi nee is required to 

prevent relapses and ell'ect a complete cure of well-marked cases. The parasiti- 
cide can be used more freely at night and less freely by day. or for the latter 
period impalpable boric acid or nosophen powder may be dusted over the parts. 
Cases that tend to recur may be effectively treated with the Rbntgen rays. Treat- 
ments of four to ten minutes' duration, twice weekly for three weeks, will gen- 
erally accomplish the end. In kerion of the beard, the editor has seen rapid 
resolution and healing follow five treatments with the A'-rays. 

The internal treatment of all forms of ringworm is important, and to be 
based on general and local conditions found in each case. As the result of 
considerable observation I am convinced that the disease is materially short- 
ened under the influence of indicated drugs, which probably act to stimulate 
nutrition and resistance of the surface tissues. See indications for Bary. carb., 
Graph.,. Kali biclirom., K. carb., K. sulph., Lye, Merc, biniod., Mez., Nat. 
mur., Pltos., Phyto., Sepia, Sul., Tellurium. 



TINEA VERSICOLOR 

(Chromophytosis; Pityriasis versicolor; Mycosis microsporina ; Dermatomyco- 

sis furfuracea.) 

Definition.— A parasitic affection of the skin, due to the presence of 
a vegetable fungus and manifested by the occurrence of irregular, variously 
sized, yellowish-brown patches, usually situated upon the trunk. 

This is one of the less common diseases of the skin, of a rather long dura- 
tion, owing probably to its not being recognized, or to neglect of proper treat- 
ment. Most cases which have come under the author's observation have had a 
protracted clinical history, apparently for the reasons stated. 

Symptoms. — The disease begins in pin-head to pea-sized, roundish macules, 
scattered irregularly over the region involved. The spots are yellowish in 
color, well defined, usually scaly, which can be made more apparent by rub- 
bing the affected surface; the smaller lesions may enlarge, and coalesce into 
larger, irregular map-like patches, sometimes of wide dimension. They are 
commonly dry unless the perspiration is active, and then occasionally have an 
oily feel to touch; they are generally unattended with any subjective symptoms, 
though itching in some degree may be experienced by the patient when warm. 
Practically tinea versicolor is an affection of the trunk, most frequently of the 
anterior surface of the chest|. but not uncommon on the back and abdomen, 
sometimes extending out upon the arms, up onto the neck, down upon the but- 
tocks, onto the groin, and onto the inner surface of the thighs. According to 
Ziemssen, the disease is of frequent occurrence in men in the latter location 
where the scrotum comes in contact with the skin of the thighs. One case of 
chromophytosis has been reported as occurring on the face, though the fungus 



316 



TINEA VERSICOLOR 



has been found in the beard and on the scalp. It is rarely seen on the upper 
part of the neck. In a case of my own, in a woman who wore her hair low down 
over the back of her neck, the disease had extended from the back over nearly 
every portion of the same part of the neck to back of the ears and onto the scalp, 
in places a half-inch from the hair line. This woman stated that the disease 
had existed on the interscapular region for nine years and on the neck for six 
months. Probably it had been of slow development on the neck for a longer 
period, but remained unnoticed at first. In a congenial soil of accumulated 
surface scales the fungus may grow and extend rapidly its area of occupation. 
Commonly the invasion is slow, and, untreated, it may last indefinitely. One 
of my private patients, who, at her first visit, exhibited large patches of tinea 
versicolor scattered over the trunk in front from the neck to the pubic region, 




Fig. 90. — Fungus of tinea versicolor — microsporon furfur (x about 600; diagrammatic). 



and on the back down to the nates, gave a clear history of eighteen years' dura- 
tion, never quite disappearing in that time. 

In some cases considerable erythema may coexist, imparting a reddish tinge 
to the coloration, which fades on pressure ; and rarely eczema tous inflammation 
may be excited by the parasitic growth. Occasionally the patches may be dark 
brown in color, and in hot climates are said to be sometimes quite black (pityri- 
asis nigra). Curiously enough, in the colored race the fungus may produce 
gray or white patches on the skin. 

Etiology and Pathology. — Tinea versicolor is so" feebly contagious that 
it is not readily communicated from one person to another. Thus, a person with 
the disease well developed may sleep in the same bed with another for years 
without infecting the latter. This indicates that a certain condition of the 



TINEA VERSICOLOR ; il" 

skin favorable to the growth of the fungus musl pre-exist, though apparently 
unconnected with lack of care of the skin or the general health. In tact, the 
disease is most common between twenty and thirty-five, a period of life when 
physical vigor is above the average, and it is rare in the extremes of age. It is 
said to occur more often in the consumptive and in those who perspire freely, 
two conditions not infrequently related to each other; but whether this seem- 
ingly etiological bearing on the disease in question be direct or incidental to a 
general or local derangement of nutrition is problematical. Dyspepsia and 
seborrhoea have also been named as predisposing causes. The disease may occur 
in any climate, but is most frequent in warmer latitudes. It is located in the 
corneous layer of the epidermis, where the causal element, a vegetable mould, 
is found. This parasite was discovered by Eichstedt in 184G and named by 
Eobin microsporon furur. For microscopical examination scales scraped from 
a patch may be first treated with ether to dissolve out the fat, then moistened 
with dilute liquor potassse and flattened out on the glass slide. Both the spores 
and threads are stained more readily by eosin and methyl-violet than those of 
ringworm or favus. Under the microscope the spores are found to be larger than 
those of ringworm, round and nearly uniform in size, and more or less grouped 
in grape-like bunches. The mycelia are quite numerous, rather short and gen- 
erally unbranched, but often interlacing and connecting different groups of 
conidia. These contain 3 r ellowish nuclei which possess strong refracting power, 
and are supposed to produce the color of the lesion. With removal of the super- 
ficial corneous cells this discoloration disappears, leaving the surface normal 
or slightly reddened. 

Diagnosis. — The location, as a rule, on the trunk, of variously shaped and 
sized patches of yellowish discoloration, slightly scaly, and which can be made 
to almost if not quite disappear at any point by scraping with a knife, are to- 
gether pretty distinctive of tinea versicolor, and in case of doubt should lead to 
microscopical examination of the scales. 

It might be confounded with chloasma, erythrasma, seborrheic dermatitis, 
pityriasis rosea, macular syphilide and vitiligo. 

Chloasma occurs on the face chiefly where tinea versicolor almost never ap- 
pears ; it is not scaly, cannot be removed by scraping and contains no fungus 
elements. Erythrasma occurs on the moist regions of the skin, in darker 
patches, and the organisms found in its lesions are very much smaller than the 
fungus of tinea versicolor. Seboirliccic dermatitis in its evolution may show 
in yellowish colored patches, but it is not usually confined to the trunk, seldom 
merges into widely extended yellowish patches as seen in tinea versicolor, the 
scales are fatty and larger, and the microscope would not reveal the presence of 
the conidia and mycelia of the latter. Pityriasis rosea runs an acute course, i< 
not commonly limited to the trunk, lias silvery scales ami the patches only lie- 
come slightly yellowish as it is fading away. The macular syphilide, though 
of a light yellowish-brown color as tinea versicolor, occurs in discrete, round 
spots, which may be found on the face and limbs as well as upon the trunk, and 
usually in association with other signs of syphilis: moreover, the maculations 



318 TINEA IMBRICATA 

are devoid of scales and fungi. The vitiligo lesion, due to loss of pigment, is 
round and the contiguous pigmented border concave, while the border of dis- 
coloration in tinea versicolor is convex and the scaliness and other features of 
the surface are absent in vitiligo. 

The prognosis under sufficient and continued treatment is always good. 

Treatment. — Almost any simple parasiticide thoroughly and persistently 
applied will cure tinea versicolor. Even mechanical removal of the outer 
corneous layers of epithelial cells by frictions with pumice stone and soft soap 
is effectual; it is wiser, however, to use an antiparasitic. Nothing is better 
as a routine prescription for all cases than hyposulphite of soda in saturated 
solution in water. The skin should be well scrubbed with warm water and 
soap, dried, and the sodium hyposulphite lotion thoroughly rubbed in with 
a piece of coarse towelling or flannel. This should be repeated once or twice 
daily until all evidence of the disease is removed, which may take from one 
to twcTweeks, rarely longer. Thereafter, for at least a month, the treatment 
should be occasionally renewed, and for some time longer strict watch of the 
skin should be kept to detect and stamp out any tendency to relapse. Most 
fresh outbreaks after apparent cures are due to neglect of these precautions. 
When the surface involved is not large, painting the patches with tincture of 
iodine, as advised for tinea circinata, is an effective and quick method of cure. 
Probably use of any of the mild parasiticides efficient in superficial ring- 
worm would prove satisfactory. In all cases the underclothing should be 
baked, boiled, or destroyed, to prevent reinfection from that source. Internal 
remedies may be given as indicated. See Kali carb., Kali sulph., Nat. arsenicum. 



TINEA IMBRICATA 

(Tokelau or Boivditch Island ringworm; Chinese, India or Burmese ring- 
worm; La Pita; Gune; Cascadoe; Herpes desquamans; Malabar itch.) 

Definition. — A tropical contagious affection, due to a vegetable fungus, 
and characterized by the development in the skin of concentrically placed, 
scaly rings. 

Fox, from observation of the disease in the Gilbert Islands, first described 
it in 1844. Manson, who observed cases in China and other sections of Eastern 
Asia, gave to it the name tinea imbricata and proved by inoculations with the 
fungus that it always produced the same disease. It is chiefly from his article 
in the British Journal of Dermatology. January. 1892. p. 5. that the material 
for the following brief description was obtained. 

Symptoms. — As shown by experimental inoculations, the disease has a 
period of incubation of about nine days. Xear the end of this time the 
fungus, which has meanwhile developed deep in the epidermis as a brownish 
mass, produces a round elevation of the skin. When this has reached a diame- 
ter of about three-eighths of an inch the central part of the patch gives way 



TINEA IMBRICA1 \ 819 

and is shed, leaving an attached rim or ring next to the sound skin. Tin 
dermis and fungi in the centre may be entirely thrown off or dislodged by 
friction, exposing the pale corium underneath. The fungus growth continues 
to advance at the periphery, showing through the epidermis a brownish and 
slightly elevated rim about one-sixteenth of an inch wide. When the whole 
ring has attained about a half inch in diameter a brownish patch is observed 
to be again forming in its centre; this in turn bursts through the young 
epidermis and forms in the same manner as before a second ring inside the 
first. Both rings continuing to advance outwardly and additional rings being 
continuously evolved at the centre, an endless series of concentric rings is 
produced. Unchecked it may thus invade a whole region or extend over nearly 
the entire body except the scalp. The latter is very rarely attacked and then 
the fungus does not invade the hair follicles. The average rate of extension 
in a single patch is about three-eighths of an inch a week, and when fully 
developed the rings may be about one-fourth of an inch apart and covered 
with scales, which are free at their outer edge and somewhat curled up. The 
surface appearance has been likened to watered silk. In advanced cases the 
epidermic scales may become large, thick and hard, looking as though the skin 
had been plastered with clay. The scales vary in size up to a half inch in surface 
diameter. After desquamation has occurred circles or sinuous lines of pig- 
mentation are seen, which may persist and sometimes remain permanently. 

The most suffering to the patient arises from the intense local itching and 
heat, and from the disfigurement when a large area of skin is involved. The 
general health is never affected and the lesions very rarely appear on any part 
of the face or head. 

Etiology and Pathology. — The disease is endemic in some tropical re- 
gions, evidently contagious, and attacks both sexes, at all ages, but children 
most often. Manson believes that it is dependent on some peculiarity of 
climate for its development. This observer and Koniger were the first to estab- 
lish the parasitic nature of the disease and its essential cause a fungus growth 
in and under the epidermis. This parasite resembles the fungus of tinea 
circinata, but is much more abundant; the spores may greatly exceed the 
mycelia in number ; and while the former are about the same size as the spores 
of tinea circinata, they differ in shape, as a rule, from the globular form of the 
latter in a varying degree to oval, rectangular or irregular forms. The mycelial 
filaments are long, straight, or slightly curved. The fungus does not penetrate 
beyond the mucous layer of the epidermis and does not enter the hair follicle. 
Examination may be made by treating the scales with liquor potassae. 

Diagnosis. — This presents no obstacle in countries where the disease is 
endemic. Its course of development by successive rings inside of the pre- 
ceding and outwardly advancing rings and the non-involvement of the hair 
follicles easily distinguish it from ringworm of the body, which commonly 
clears in the centre and only develops at the periphery. The microscope will aid. 

Treatment. — The methods recommended are practically the same as for 
the more severe forms of tinea circinata. The clothing should be destroyed or 



320 ERYTHRASMA 

thoroughly disinfected, and the scales removed with alkaline baths. Manson 
advises painting the affected regions daily with strong iodine liniment, extend- 
ing its application over a wider surface each time.' Under this or other appropri- 
ate means of cure and prevention, the prognosis is favorable. 



ERYTHRASMA 

Definition.- — A mildly contagious affection of the skin due to a vege- 
table parasite, and characterized by the formation of brownish patches, 
usually located on parts of the surface in contact. 

'Symptoms. — The disease occurs in small, well-defined erythematous or 
scaly macules, which later become yellowish or brown in color. At first round- 
ish in outline, the patches may become irregular and very slowly increase, but 




Fig. 91. — Fungus of erythrasma — microsporon minutissimum (x about 600 ; diagrammatic). 

rarely exceed a silver dollar in size, and are few in number. They are some- 
what scaly, especially at the periphery, slightly greasy to the touch, and are 
not easily separated from the epidermis. They are situated almost exclusively 
on the opposing folds of the axilla?, genito-crural and inguinal regions, between 
the nates and on surfaces contiguous to these parts. The disease rarely extends 
far away from the warm and moist regions of the skin, but has been observed 
to spread. out upon the thighs and arms, and may arise independently of the 
usual sites. Subjective symptoms are absent or moderate itching may be 
felt, but often the affection is so trivial that its existence is only accidentally 
discovered, and untreated it may exist for years little changed or noticed. 

Etiology and Pathology. — Erythrasma occurs exclusively in adult life 
in either sex, but more frequently in men. The parasitic element in the causa- 
tion of this disease was discovered in 1862 by Barensprung, who gave to it 



DHOBIE ITCH 821 

Hie name oi' microsporon minutissimum. Unna says that tins form is dis- 
tinction to the microsporon shows no isolated collections of spores, but they 
are irregularly scattered singly and in collections between hyphae or mycelia, 
and are very minute. The parasite grows in the epidermis, but does no! Loosen 
the horny layer as a whole; when that layer is removed on plaster the stained 
fungus shows as a dense felt-like collection of very line, twisted and winding 
mycelia. A power of five or six hundred diameters is required to clearh 
the organism. Miehele claims to have reproduced the disease in the inguino- 
scrotal region by inoculation with a cultivation of the fungus, and to have 
found the leptothrix in cases of supposed erythrasma. 

Diagnosis. — Even without the microscope little difficulty will be found in 
distinguishing erythrasma from other affections of the surface. Eczema mar- 
ginatum has the same sites of preference, but the latter is distinctly inflamma- 
tory in type with consequent well-marked local disturbance, an elevated and 
advancing border, and often it is acute in its development, all unlike ery- 
thrasma. Tinea versicolor occurs as a rule on the trunk and rarely extends to 
(lie common sites of erjdhrasma, which is redder in color, but shows less 
disturbance of the horny epithelia and cannot be readily rubbed away. Pity* 
riasis rosea would scarcely be confounded with erythrasma from its wider dis- 
tribution, short course, etc., and chloasma, due entirely to increase of pigment, 
is still less likely to be mistaken for the disease in question. Both of the last- 
. named diseases are non-parasitic, and in all cases of doubt a microscopic exami- 
nation will determine as to the presence of a parasite, and, if found, as to its 
diagnostic significance. 

Treatment. — The same measures of cure and prevention of relapse as 
suggested for tinea versicolor are adapted for use in erythrasma. Kali sulph. 
may be indicated to improve the tone of the skin. 



DHOBIE ITCH 

(Manila itch; Crutch itch; Dermatitis mycotica.) 

Various epiphytic diseases of the skin may be included under this name. 
They all occur in tropical climates including the Philippine Islands, and 
particular species are known to be caused by the trichophyton, microsporon 
minutissimum, and microsporon furur, while others are bacterial, a form 
of pemphigus contagiosa. In tropical countries, the resulting dermatitis may 
be severe and may become pustular from bacterial infection. Of the ten cases 
of so-called Manila itch seen by the editor all gave clear histories of direct 
or indirect contagion from persons formerly resident or now residing in the 
Philippine Islands. In a majority of these cases, the abdomen and the leg-; 
were the main parts affected with a papulo-pustular eruption, which i tihed 
incessantly, and on disappearing left pigmented spots. 

Treatment. — Parasiticides are always required. Linimentum iodi, tino 



322 BLASTOMYCOSIS 

» 

ture of the leaves of cassia lata, chrysophanic acid and mercuric chloride 
(1: 1000) have all been recommended. Cases treated in temperate climates 
need less severe treatment. Equal parts of sulphur and zinc oxide ointments, 
to which resorcin in five per cent, strength has been added, is usually efficacious. 
Internal remedies are similar to those recommended under ringworm. Prophy- 
laxis should not be neglected. 



BLASTOMYCOSIS 

(Blastomycetic dermatitis; Saccharomycosis homims.) 

The records of about fifty cases in which the nature of this affection has 
been noted are available for study, and it is to American investigators that we 
owe most of our knowledge of this rare parasitic disease. Blastomycosis may 
be described as chronic, inflammatory and infectious. It first appears as a 
small papule which may remain unnoticed for months, or the initial lesion 
may be a papulo-pustule which in time becomes crusted. Enlargement takes 
place peripherally and a sharply outlined elevated verrucous patch is formed; 
the base of which is bathed in a sero-purulent secretion and presents a sloping 
border in which are minute deeply seated abscesses. This border is smooth, 
red to purplish-red in color, and from one-eighth to three-eighths of an inch 
in width. An individual patch may take months to attain a diameter of one 
inch and may remain indolent for months or years afterwards. Usually other 
patches develop after the original one has existed for some weeks. Healing 
may be spontaneous or gradual; the centre often clearing up as the disease 
ends at the periphery. The flattening and gradual disappearance of the 
papillary projections, the diminution of the serous discharge, decrease in num- 
ber of the miliary abscesses, and the formation of hypertrophic scar-like tissue 
which eventually becomes the characteristic soft, supple, pinkish-white cicatrix, 
are the steps in the resolution of a patch. Eegions which are most accessible to 
infection, as the face, hands and arms, are more commonly involved. The 
majority of patients are in good general health and have few subjective sensa- 
tions. Systemic infection may take place and give rise to pyaemia, subcu- 
taneous abscesses and bone necrosis. 

Etiology. — Sex, occupation, nativity and habits do not seem to exert any 
influence. About half of the cases have appeared after the fortieth year. 
Blastomycetic infection may be secondary to lesions of other diseases or to 
trauma, but the sole cause is a local infection with the fungus, pathogenic 
to each individual case. The infectious nature of the disease is proven further 
by the successful inoculation of animals. 

Pathology. — The characteristic miliary abscesses are found in all parts 
of the hyperplastic epithelium, and may break through to the surface. The 
epidermis is separated from the corram by a distinct layer of columnar cells : 
the rete cells are large and swollen, the prickles being conspicuous ; premature 



MYRINGOMYCOSIS— PINTO DISEASE 828 

cornification occurs in groups of cells; the coriuni is the seat of a variety of 
inflammatory changes including dense infiltration. The blastomycetes may be 
demonstrated by subjecting a section of the diseased tissue or some of the puru- 
lent discharge to a strong solution of potassium hydroxide. The parasite i3 
then seen to be a round, oval, or irregular body having a well-defined capsule, 
and a granular protoplasm. Mycelium has not been found in the abscesses 
or in the tissues, but the blastomycetes may be obtained in pure culture from 
the minute abscesses in the borders of the lesions. 

Diagnosis. — Verrucous tuberculosis may so closely resemble this disease 
that a microscopic examination will be found necessary. Other conditions 
which may need to be differentiated are lupus vulgaris and other cutaneous 
manifestations of tuberculosis, the vegetating forms of syphilis, and proto- 
zoan infection which is probably a form of blastomycosis. 

Prognosis. — This disease should be completely cured under careful and 
prolonged treatment. Eecurrences are common, however. Cases with systemic 
involvement usually prove fatal. 

Treatment. — Cleansing and antiseptic lotions are always indicated. Com- 
plete excision and curetting have likewise been of service, but the most success- 
ful treatment appears to be large doses of the iodide of potassium plus a few 
exposures to the Rontgen rays. The tissue salts might be studied in con- 
nection with this disease and its internal treatment. 



MYRINGOMYCOSIS 

(Otomycosis.) 

The aspergillus (niger, flavus, fumigatus) may develop in the external 
ear when the aural epidermis has been macerated or otherwise diseased. In- 
spection will show in the canal white masses covered with gray, yellow, green, 
brown or black spots. Microscopic examination reveals spores and a few 
flower-like masses which are composed of the sporangium of the fruit-capsule 
of aspergillus. Deafness, tinnitus aurium, otorrhcea and eczematous inflamma- 
tions are usually present in varying intensity. Lowenberg recommends for the 
destruction of this mould the application of dilute alcohol followed by pow- 
dered boric acid. 



PINTO DISEASE 

(Mai del pinto; Pinta disease; Spotted sick7iess, etc.) 

Definition. — A disease of the tropics, due to a vegetable fungus, char- 
acterized by the appearance on the skin of various shades of discoloration, 
and attended with itching and desquamation. 



324 PINTO DISEASE 

This peculiar affection is limited in geographical distribution to the equa- 
torial latitudes of Mexico, Central and South America, not extending beyond 
27° and 28° north or south. It is endemic in Mexico and is said to have 
existed there in the time of- Cortes, and to have been mentioned by the Aztecs 
in their prayers for centuries. The first authentic record of it was made in the 
Encyclopedia of Polanko of Mexico, in 1760. 

The disease appears on the skin in the form of scaly spots, of various sizes, 
shapes, numbers and colors. It may involve from a small area up to a general 
distribution over the whole body, except the palms and soles. It begins as a 
rule on exposed parts, such as the extremities or face. Its frequency on the 
face in Venezuela and Granada gave rise to the name caraate or cute, i.e., 
"Look at his face." The lesions are usually bilateral, seldom symmetrical, 
and only slightly raised above the surface. They grow by peripheral exten- 
sion and may remain discrete or coalesce with neighboring lesions while new 
spots"cbntinue to appear. In shape the patches thus formed may be round or 
irregular, sharply defined or merging into the surrounding skin in shades of 
gray, blue, black, red or white, which do not disappear on pressure. These 
variations in color depend somewhat on the depth of the skin affected by the 
disease. In a single case any or all colors may successively appear at some 
stage and mingle together; in another case only one shade may show, but 
whether in single or multiple colors the individual spot remains the same 
throughout the course of the disease. Occasionally, in the advanced stage, 
tubercle-like lesions may appear. The superficial tj-pe of the disease does not 
penetrate into the mucous layer of the epidermis, and when it disappears under 
treatment leaves no trace behind, though the blue form may have presented 
previously the appearance of indelible gunpowder stains of the skin. On 
the other hand, the red and white varieties may involve the rete and the 
entire corium; the red form sometimes resulting in ulceration, and the white 
form presenting a hard, scar-like aspect attended with diminished sensation. 
When hairy parts are attacked, the hair loses its color, becomes thin and falls 
out. Scaliness is furfuraceous at first, but later the scales may become larger 
and the surface dry and rough, and sometimes greasy or humid. The itching 
is generally in direct ratio to the scaliness and is often intense, especiallv at 
night; the odor of the skin is offensive and has been compared to dirty, mouldy 
linen and to cat's urine. Though the disease may become slowly or rapidly 
extensive and involve nearly the entire surface of the body and show no ten- 
dency to recovery if left to itself, constitutional symptoms are absent and 
inflammation seldom occurs. 

Etiology and Pathology. — Numerous cases of communication from 
one person to another seem to establish the contagious nature of pinto disease. 
It occurs in both sexes and at all ages except in young infants. Moisture 
as well as warmth appears essential to its development, as it does not originate 
at high elevations. An existing irritation of the skin or dermatitis, especially 
amid \mhygienic surroundings, favors its onset. The native or colored races 
are much more susceptible to the disease than white people. The efficient causal 



ACTINOMYCOSIS OF THE SKIN 

factor has been shown to be a cryptogamus i'ungus of the aspergillus family, 

which appears under the microscope as round or oval sporee attached to 
branched and tapering mycelia filaments. These grow in the corneous layers 
of the epidermis in the superficial forms of the disorder, and penetrate the 
rete macosum and sometimes into the corium in the deeper varieties. Perma- 
nent whitening of the surface tissues may remain to mark the sites of the 
latter. There is some doubt as to the parasitic nature of the blue variety. Lier, 
from his investigations of the disease among Mexicans, concluded that the 
blue form was an anomaly of pigmentation, and all attempts to reproduce 
this form of the disease by inoculation on himself and others failed. It has 
not been determined whether the change in color is due to variations in the 
fungus or to pigmentation of the spores and mycelia. Some other unidentified 
discolorations of the skin which have been observed in the tropics may or 
may not be allied to the disease in question. An affection known in Surinam 
as lota is said to resemble pinto disease. 

Diagnosis. — The peculiar objective features, odor and absence of constitu- 
tional symptoms in connection with its endemic type in certain tropical regions 
makes mal del pinto easy to recognize in countries where it prevails. 

Treatment. — For the superficial forms this is practically the same as for 
tinea versicolor. In the deeper situated varieties probably some of the more 
penetrating applications such as naphthol, iodine or chrysarobin would be of 
greater utility. Relapses must be guarded against as in other allied forms of 
parasitic disease. 



ACTINOMYCOSIS OF THE SKIN 

Definition. — A chronic parasitic affection due to the presence of the 
ray fungus in the subcutaneous or other tissues, which attacks the skin 
secondarily from within, producing nodular swellings or tumors and 
numerous fistulous openings on the surface. 

Actinomycosis of internal organs is of less rare occurrence than in the skin. 
but the cutaneous form is probably not so rare as formerly supposed. The 
disease occurs in some of the lower animals, and Bollinger in 1877 first demon- 
strated the presence of a fungus in the lesions of the 'lumpy jaw" of cattle, 
which from its gross appearances Harz termed the "ray fungus." Two years 
after Ponfick established the identity of the disease as it occurred in man and 
animals, and later Maiocchi described its occurrence in the skin. The fungus 
gains access to the tissues in nearly all cases through the mouth, most often 
along a carious tooth, but may find entrance further on in the digestive or 
respiratory tracts. Very rarely the skin may be affected from without through 
some break in its surface. 

Symptoms. — In the larger proportion of cases the disease is situated in 
parts contiguous to the mouth and neck, often at the side beneath the jaw, but 
the hand, foot, leg, scrotum or shoulder may be affected. The onset of the 



326 



ACTINOMYCOSIS OF THE SKIN 



disease is insidious, and months or years may elapse before the skin is affected. 
Sooner or later deep subcutaneous tumors develop covered by the dark red 
or livid skin, which, as it becomes more involved, bursts at one or more points 
and gives outlet to a thick, purulent discharge which later becomes sero- 
sanguineous. Sometimes as the tumor-like swelling becomes soft, burrowing 
of its contents takes place, and an opening in the skin may occur followed by 
a discharge at some distance from the tumor. Short or long fistulous tracts 
are thus formed, much the same as in scrofuloderma. The special features of 
the discharge are the presence in it of numerous minute, yellowish bodies, 
from a small pinhead to a hemp-seed in size, which consists of massed myce- 
lium of the actinomyces or pathogenic fungus. The course of the disease varies, 
but is invariably chronic, slowly but steadily invading new tissue, with a min- 
gling often of hard and soft cutaneous and subcutaneous nodules, some of them 
situated about the orifice of the sinuses, bluish-red or purplish in color. Very 
-— v rarely the indurations remain persistently hard, 

and may subside without cutaneous rupture and 
discharge, or an opening may occur in a blood- 
vessel and the infecting element is transported 
in the blood to internal organs, particularly to 
the lungs. The disease in internal organs may 
or may not lead to a fistulous opening on the 
surface. Secondary infection of the lesion with 
pus cocci may occur, in which cases swelling of 
the lymphatic glands may follow, and even ex- 
tensive suppuration and pyaemia may ensue, but 
unmixed actinomycotic infection does not tend 
to involve the lymphatics. 

Etiology axd Pathology. — Men are more 
often attacked than women, owing to their occu- 
pations bringing them more in contact with ani- 
mals subject to the disease. An interesting case 
was observed by Murphy of Chicago, in a 
woman whose pet dog had previously died with a large swelling under the 
jaw. The habit of chewing a blade of straw or hay has been noted in some 
who developed the disease, and in most eases patients with the disease have 
been found to have carious teeth, and one case has been reported of direct 
infection through a splinter wound of the foot. One case observed by the 
editor was due to direct infection from a horse who had lumpy swellings on 
the legs. Some break in the continuity of surface tissue is probably a neces- 
sary condition for entrance of the fungus into the tissues. Healthy animals 
fed with the cultures of the ray fungus do not take the disease, but the same 
animals inoculated with the culture under the skin develop it. Choux believes 
the disease differs in man and animals, in that the reaction of the human 
tissues to the fungus is attended with suppuration, while in animals hard, 
tumor-like growths resembling sarcoma result from the same fungus. The 




Fig. 92. — Actinomyces 
(Diagrammatic after Ponfick.) 




Fig. 93.— ACTINOMYCOSIS OF THE SKIN 

Patient, an American, of fifty. Duration of disease, eighteen months. Com- 
menced on the right leg as an erythematous scaly patch; then spread to both legs 
and feet, showing nodules, subcutaneous sinuses, ulcers, and pustules. Microscopic 
examination revealed the actinomyces in great number. A history of handling a 
horse that showed lumpy swellings on the legs is the only suggestive causal fact. 
Symptoms of pain, swelling and tenderness were relieved by the use of calcarea 
fluo., sixth decimal. For the last five months the improvement has been steady 
under the local use of peroxide of hydrogen and the internal use of the iodide of potas- 
sium, saturated solution, from fifteen to sixty drops daily. 



^^^^^^^^^^^w 




% ■ J 










■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■I 




W 




■■^^^ ^■■■■■■■■■l 


w^^^ ^^ftM jj^^M 



Fig. 94.— ACTINOMYCOSIS OF THE SKIN 
Same case as Fig. 93, showing the inner aspect of the right leg. 






ACTINOMYCOSIS OF THE SKIN 327 

causal identity and relation of the parasite to the disease in both man and 
animal has been completely established. 

The ray-fungus, found to compose the yellowish bodies visible to the naked 
eye in the discharges before mentioned, when pressed between the slide and 
cover glass (stained by Gram's method), are seen under the microscope to 
consist of mycelia, which interlace centrally and give off threads which radiate 
therefrom singly or after dichotomous division, and expand at their distal 
end into club-shaped enlargements. These club-shaped bodies are thought to 
bo the spores or fructifying parts of the fungus. This organism is found 
throughout the tumor mass as well as in the discharge. According to Unna, 
the ray fungus belongs to those organisms which have a sort of chemical attrac- 
tion for leucocytes and induces suppuration at once; therefore, he excludes 
the idea of a mixed infection to explain the suppuration in actinomycosis 
hominis. However, the consensus of opinion is that actinomycosis is pro- 
duced in the human body by pathogenic micro-organisms, and not by a single 
specific ray-fungus. Two divisions of the genus actinomyces are now recog- 
nized, the acid-resisting and the acid-bleaching types, but the exact pathological 
being of each is not yet differentiated. 

Diagnosis. — After rupture through the skin and discharge from the nodu- 
lar swelling has taken place, little difficulty ought to be found in recognizing 
actinomycosis, as the yellowish masses of fungus are always present and can 
be demonstrated microscopically. While the tumor remains unbroken the 
disease cannot be always differentiated from sarcoma, carcinoma or scrofulo- 
derma. Though occupation about animals, in or about the stables, etc., a 
carious tooth previous to the growth of the tumor and absence of glandular 
enlargement would be suggestive of actinomycosis. 

Sarcoma involving the skin is more likely to be painful to motion or 
pressure than actinomycosis tumors, less apt to break down, and when this 
does occur takes the form more often of a single central slough. Carcinoma 
is commonly painful, and the lymphatic glands become involved sooner or 
later. Scrofuloderma originates chiefly in childhood and youth, and always 
involves the glands, while actinomycosis usually begins in adult life and does 
not. as a rule, implicate the glands. In cases of great doubt an exploratory 
incision might be justifiable to obtain a section of the tumor for examination 
as to the presence of the fungus. Non-discovery of the parasite, however, 
cannot be said to be proof positive of the non-existence of actinomycosis. In 
such a case Legain inoculated the skin of a rabbit with the scrapings from an 
abscess which gave rise to the growth of a hard nodule "containing the ray fun- 
gus. Care should be taken not to mistake dental abscess or sinuses for actino- 
mycosis. The absence of the nodular tumors and the communication of the 
pus cavity with the bone underneath would be significant of the former. 

Prognosis. — This may be poor in any case although internal actinomycosis 
of wide extent has recovered spontaneously. Intestinal involvements are grave. 
Schlange and others have lately reported good percentages of cures. Prompt 
and thorough removal of all diseased tissue makes the prognosis more favorable. 



o-lS MYCETOMA 

Treatment. — The surgical and antiparasitic are the methods adapted for 
the treatment of actinomycosis. Extirpation in suitable cases is without doubt 
the quickest mode of cure ; when rupture and discharge has taken place and the 
case is not favorable for extirpation of the diseased tissues,, sinuses and abscess 
cavities may be opened up, curetted and treated antiseptically. Among anti- 
parasitic measures for inter-tissue treatment of the growths either before or 
after external rupture, the electro-chemic method of Gautier should be men- 
tioned. This consists in inserting two platinum needles into the tumor and 
passing a current of fifty milliamperes through its substance at the same time 
that every minute or two a few drops of ten per cent, solution of iodide of potas- 
sium is injected into the part. Nascent iodine is set free in the tissues, and 
the treatment can be kept up in different parts of the growth for about twenty 
minutes. It is too painful to be employed without an anaesthetic, but most 
satisfactory results have been reported by Gautier, Darier and Meurier and 
others.'T'ases have yielded to the administration of ordinary doses of iodide 
of potassium, and it is quite possible that injections into the growth of 
tincture of iodine might be nearly as efficacious as the electro-chemic plan, 
and could be done without an anaesthetic. Three cases have been observed by 
the editor; one involving a large portion of both legs (male subject) is 
receiving iodide of potassium, nine to fifteen drops of saturated solution daily, 
with calcarea fluorica 6x as an intercurrent remedy. Hydrogen peroxide in 
one- third strength is injected twice daily into all openings. Another case 
(male subject) involving the neck and jaw was cured in three months with 
the iodide of potassium, and hydrogen peroxide used in the same manner as 
above mentioned plus the continual use of a wet dressing of the same lotion. 
The third case, involving the palm of one hand, M-as cured in two months by 
means of the peroxide and hepar sulphur 3x. This last case (that of a 
woman) previously had the same condition on the other hand. In all these 
cases microscopic examinations revealed the ray-fungus in abundance. 

Physiological methods to support the system and indicated drugs to give 
increased tone to the tissues should be selected in each case. Kali brom. might 
be studied in addition to the remedies mentioned above. 



MYCETOMA 

(Podelcoma; Ulcus grave; Madura foot; Fungus foot of India; Tubercular 

disease of the foot.) 

Definition. — An endemic affection of the skin and deeper structures, 
usually confined to the foot, leg or hand, and probably due to a parasitic 
fungus. 

The disease is endemic in India, has never occurred in Europe, and onlv 
with extreme rarity in America (five reported cases in North America). 
Symptoms. — Beginning insidiously and superficially the disease may show 



MYCETOMA : ^ ,J 

upon the surface in the shape of swelling, large vesicles, papules, pustules, or 
tubercle-like elevations, which sooner or later burst and give exit to a thin, 
sero-pu ru lent or sanious discharge containing at times whitish poppy seed- 
like granules, caseous particles, or blackish masses which have been compared 
to lish-roe. The black variety is more common than the pale form, contain- 
ing only the lighter colored matter in the discharge. In mild cases a single 
toe or linger may be involved ; in other cases, the lesions may be numerous, and 
sometimes discolorations of the surface in blackish or bluish macules or dots 
may precede any break in the surface of the skin. Very gradually the disease 
may progress by a sort of tunneling into the tissues for months or years until 
the foot, riddled with sinuses extending first into the soft parts of least resist- 
ance and then into the periosteum and bones, becomes misshapen and useless. 
Essentially chronic in its course, the disease may last for twenty or thirty 
years, but frequently the whole foot may become involved in from two to six 
years, and perhaps swollen irregularly to two or three times its normal size 
and weight. The leg or the hand is less commonly attacked, and rarely the 
scrotum or other parts are affected. Unless arrested by treatment, the disease 
always tends to increase progressively, involving new tissues in the process 
of disintegration, until the patient dies from exhaustion or from some inter- 
current malady. There is a striking absence of glandular implication, and 
no case of septic poisoning has been noted from the disease. 

Etiology axd Pathology. — Mycetoma is endemic in India, and said to 
be more common among natives who work barefooted in the fields, and to attack 
males more often than females; it is usually attributed to some injury of the 
part by puncture with a thorn or splinter, or from a bruise. This mode of 
origin is supported by the fact that many cases begin on parts most exposed 
when uncovered to accidental wounds, such as the plantar surface of the toe, 
between the toes and the palmar surface of the finger or thumb. Yet this origin 
is not proven, and nearly always the first sign of the disease appears to be some 
distance under the skin, and located without any relation to a definite point. 

The pathogenic cause is a fungus, which if not identical with, is closely 
related to. that of actinomycosis. The latter disease, however, seldom occurs 
in India where mycetoma is indigenous, and, unlike mycetoma, attacks the 
internal organs. The actinomyces are brilliantly colored by acid fuchsin, 
while the fungus found in mycetoma reacts indifferently to it. Vandyke 
Carter, who first isolated a fungus in the black variety of the disease in 18 T4-. 
and for whom it was named chionyphe Carteri, from further microscopic 
studies of the lesion believes mycetoma to be a direct form of human actinomy- 
cosis. "With this opinion Crookshank also agrees, while Hewlett, in 1892. 
claimed to have demonstrated the presence of the ray fungus elements in the 
particles contained in the discharge from the pale variety. However the exact 
class to which the causal parasite of mycetoma belongs has not been determined. 

Diagxosis. — A well developed case of mycetoma with sinuses, in the dis- 
charge from which can be found the blackish or whitish bodies above named, 
especially in the country where it is endemic, could hardly be mistaken for anv 
other disease. 



330 IMPETIGO 

Treatment. — Early and complete surgical removal of the diseased part 
is said to be the only effective method of treatment. If confined to narrow 
limits scraping away the affected tissues may be sufficient, or early amputation 
of a toe or finger may be necessary, but in the late stages amputation high 
enough up to certainly include all affected parts is essential to cure. Kali 
lichrom. and K. brom. are possible remedies. Iodide of potassium as used in 
actinomycosis is useless in mycetoma. 



IMPETIGO 

(Impetigo simplex; Impetigo sparsa.) 

Definition. — An acute affection of the skin characterized by the ap- 
pearafice successively or in crops of a few discrete, firm, pea to small 
finger-nail sized, superficially seated pustules. 

Many clinical observers doubt the existence of this form apart from 
impetigo contagiosa, but the type of pustular eruption as described by Duh- 
ring is certainly not of rare occurrence, and in its course is unlike the con- 
tagious form. 

Symptoms. — Occasionally the onset of the eruption is preceded by slight 
fever, malaise and loss of appetite. The eruption consists at first of small, 
separated vesico-pustules which are so rapidly transformed into larger pustules- 
that their primary vesicular character is not often observed. When fully 
formed they vary in size from a split pea to a small cherry, yellowish white in 
color (sometimes darker from admixture of blood), globular in form, fully 
distended and appear to rest directly on the surface with or without a hypersemie 
areola. They may dry up without breaking or rupture and form honey-like 
or brownish crusts firmly attached to a slightly moist base; the scabs fall off 
after a few days, leaving no permanent trace behind. The duration varies with 
the time in which new lesions continue to appear. Occasionally these occur 
simultaneously and the course is short. More often they arise in crops or suc- 
cessively for a week or more and the duration of an attack seldom exceeds two- 
or three weeks ; but in poorly nourished and neglected children an attack may 
be aggravated and much prolonged. The eruption is located commonly on the 
face, hands or fingers of children or young people, less often on the lower ex- 
tremities and feet, shows no tendency to coalesce and rarely to become grouped, 
and is never very abundant, seldom exceeding twenty individual lesions, and 
sometimes only one or two appear. The subjective sensations are never marked 
by more than slight tension or itching, which leads to picking at rather than 
scratching the parts. 

Etiology and Pathology. — Impetigo is practically a disease of childhood, 
though occasionally seen upon the hands and fingers of adults. It is more 
common among the poor and uncleanly, but does appear in clean and apparentlv 
healthy children. Probably the instinctive habit in children of touching most 



IMPETIGO 



331 



everything with the hands, and with the latter the face, and the same disregard 
of cleanliness at this age, accounts in a large measure for its more frequent 
occurrence in young children than in infants or adults. The efficient cause is 
a mixed infection from streptococci and staphylococci. Through some slight 
abrasion these organisms find entrance into the skin and set up an inflammation 
in the papillary layer of the corium, forming a small superficial abscess cov- 
ered only by the epidermis. The lesions contain, beside pus cocci, pus corpuscles, 
epithelial cells, a few red blood corpuscles and broken down cellular matter. 

Diagnosis. — The distinguishing features of impetigo lesions are their pus- 
tular type from early beginning to the end, comparatively few number, size, 
elevation, isolation, firmness and termination in thickish crusts, without pro- 
ducing any marked local subjective or constitutional symptoms during their 
course. 

From impetigo contagiosa it can be differentiated by the contagiousness of 
the latter, its beginning as vesicles, vesico-papules or vesico-pustules, which fre- 
quently coalesce with or without rupture and dry into friable, wafer-like crusts. 
From ecthyma by the larger flat pustules of the latter, seated on an inflam- 
matory, hard and wider base, drying into bulky, brownish or blackish crusts, 
beneath which are pit-like erosions, and around all, generally, a well marked 
areola. Moreover, ecthyma is seen ordinarily in anaemic or cachectic adults, 
while impetigo is commonly a disease of childhood unassociated with any 
special ill health. Pustular eczema with its pinhead and smaller pustules ag- 
gregated in patches, often associated with vesicular and papular lesions and 
attended with infiltration of the skin and positive itching, would hardly be 
mistaken for the pea-size or larger isolated pustules of impetigo, unattended 
with infiltration or decided itching. It may be borne in mind, however, that 
impetigo-like pustules may occur in the course of other pustular diseases of the 
skin, of which eczema is the most common. I have seen impetigo once in asso- 
ciation with varicella, giving the attending physician a suspicion of the exist- 
ence of smallpox. 

Pkognosis. — This is always good; the affection tends to spontaneous re- 
covery, but may be shortened by indicated remedies. 

Treatment.— There being little tendency for impetigo pustules to rup- 
ture or discharge, no local treatment beyond ordinary cleanliness is required. 
An internal remedy can be easily selected from the character of the eruption 
and any other symptoms obtainable. Antimonium tart, is probably most often 
indicated. See also Ant. crud. and Cicuta. 



332 IMPETIGO CONTAGIOSA 

IMPETIGO CONTAGIOSA 

(Impetigo parasitica; Porrigo contagiosa; Porrigo larvalis, etc.) 

Definition. — An acute contagious inflammation of the skin due to pus 
inoculation and characterized by the formation of multiple, flat, oval or 
roundish, split pea sized or larger, usually isolated vesicles, blebs or vesico- 
pustules, which dry up in a few days into yellowish, slightly adherent 
crusts. 

Tilbury Fox first carefully described the disease in 1862, and called atten- 
tion to its being often gwosi-epidemic. The latter type has been sometimes 
described as a form of "epidemic pemphigus." 

Symptoms. — The onset of the eruption is occasionally preceded by some 
febrile disturbance. Erythematous spots or papules soon appear and rapidly 
become transformed into small vesicles or vesico-pustules, which quickly enlarge, 
^Become milky or purulent, flat, with a tendency to central depression and some- 
times decided umbilication. They vary in size from a split pea to a cherry, and 
when close together may coalesce and form large irregular patches; they are 
very superficial, and if broken show a slightly red, eroded and exuding base. 
Undisturbed they dry up in a few days into wafer-like straw colored crusts 
which adhere closely to the base. The lesions are seldom surrounded by an 
areola unless an attack is unusually severe. They are rarely numerous and may 
comprise only one or two lesions ; are most always situated on the face or hands, 
but may occur on any part of the body and exceptionally on the mucous surfaces 
of the nosq. mouth or conjunctiva. Slight abrasions of the face or hands are 
likely to be auto-inoculated and new lesions may appear singly or in crops at 
intervals of a day or two, but as a rule the disease runs its course in one to two 
weeks. The disease is very contagious, and children in the same family or 
playmates are frequently inoculated one from another, while adults of the 
same family often exhibit one or more lesions, particularly on the hands. Very 
commonly an attack is accompanied by some swelling of the submaxillary 
glands. 

Atypical forms of impetigo contagiosa are not uncommon.. Thus they may 
have unusual locations on the body or be widely scattered, pursuing the usual 
course otherwise. Or the lesions may be pemphigoid in character and two or 
three times their average size; this variation seldom occurs except in the epi- 
demic type or so-called "epidemic pemphigus" among children. Occasionally 
the vesicular stage of the eruption is lacking or so brief as to escape notice, and 
purulent lesions are present from the beginning like non-contagious impetigo 
in this one respect, and rarely the tendency to a pustular grade of inflammation 
may go on to the ecthymatous form of lesion. Even without these marked 
clinical variations there are many grades of severity and extent of the eruption 
with corresponding modifications in appearance, but still preserving some char- 
acteristic features as to origin, evolution, duration, termination, etc. 

All types, typical and atypical, may occur in any one epidemic, as was illus- 




Fig. 95.— IMPETIGO CONTAGIOSA 

Patient is a child nine years old, with a history of previous health and freedom from 
eruptions. Duration, two and a half weeks. Disease was probably contracted at school 
while at play with a schoolmate with "sores'' on her hands. Large, superficial vesico- 
pustular lesions were first noticed on fingers and chin. These dried within three days 
into yellowish crusts. Similar eruptions appeared successively on other parts of face, 
some coalescing. The last vesico-pustule, flattened and umbilicated, is situated on middle 
of right forehead. Most lesions are brownish from adherence of dust, the child dreading 
and refusing to bathe the face since the efflorescence began. Cured in five days with 
calcarea sulph., twelfth decimal, internally, and a ten per cent, boric acid ointment applied 
morning and night. 




Fig. 96— IMPETIGO CONTAGIOSA 

Patient, a boy of ten years. History of many similar outbreaks 
in the same tenement. A number of vesicles appeared on the chin 
which rapidly pustulated; within a few days thick friable crusts com- 
mence to form. The lesions were confined to area depicted, except 
four which appeared on the fingers of the right hand. Cured in one 
week with viola tricolor, third centesimal, without local treatment. 



IMPETIGO CONTAGIOSA 383 

liter's experience with nearly two hundred cases, occurring dur- 
ing (he summer of 1900 in the upper west side of New York City. 

Etiology and Pathology. — Impetigo contagiosa is chiefly a disease of 
early childhood, is much less common after the tentli year, infrequent in adults, 
and then usually mild and transient in form. While more often seen among 
the poor and uncleanly, it is not rare among children of the well-to-do classes. 
Excoriations of the skin incident to scratching from the presence of pediculi, 
scabies, urticaria, etc., may open the way for inoculation with contagious pus or 
pus cocci. Likewise may vaccination or other suppurating conditions of the 
skin, particularly in children, afford the source and favoring conditions for the 
development of the disease. In some cases no contributing causes are apparent, 
but slight abrasions of the skin in children are often unnoticed. The disease 
always rises from infection and is inoculable and auto-inoculable. 

There is no reason to doubt that micro-organisms supply the link between 
the etiology and pathology of impetigo contagiosa, and that these germs are 
the same variety of pus cocci found in the lesions of the non-contagious form. 
Whether the difference in the two forms can be attributed to some specific qual- 
ity of the organisms or to a variance in the susceptibility of the skin is un- 
determined. 

Diagnosis. — The diagnostic features of the disease are usually plain enough 
in simple cases. The isolated vesicular lesions becoming pea-sized, or larger, 
flat vesico-pustules, unattended with an inflammatory areola, indurated base or 
much itching, and commonly located in the face or hands, are quite distinctive. 
A resemblance to varicella, eczema, impetigo, pemphigus or ecthyma may exist. 
Varicella lesions are usually more or less disseminated over the trunk as 
well as on the face, uniform in size, rarely exceeding a pea, without tending 
to group or coalesce, and terminate with slight crusting. In pustular eczema 
the infiltrated skin, small pinhead pustules in patches, the marked itching, 
longer course and the absence of the large isolated pustules of impetigo con- 
tagiosa would clearly differentiate it from the latter. The two diseases may 
coexist, but other lesions of eczema will be likely to be present also in such 
cases. The comparative diagnosis from impetigo has been given under the 
latter disease. Pemphigus very rarely occurs in childhood. Its lesions (bulla?) 
are the same size from the start; seemingly spring from the sound skin, and 
have no special predilection for the face or hands. Whereas impetigo con- 
tagiosa occurs chiefly in childhood; its lesions begin small and increase by 
peripheral growth and seek especially the face and hands. In cases of doubt in 
so-called epidemic pemphigus, a day or two's observation of the evolution of the 
eruption would determine its nature. It is only when the p^^stules of impetigo 
contagiosa become transformed into ecthymaform lesions that it would be 
mistaken for ecthyma, when practically the distinction is only a difference in 
mode of origin, and some of the primary lesions of the former can be usually 
found. The latter is a disease of adult life, commonly located on the legs, and 
the lesions are deeper seated, while impetigo contagiosa is an affection of child- 
hood, usually located on the face and hands, and its lesions are very superficial. 



334 ECTHYMA 

Finally, it may be remembered that impetigo contagiosa quickly responds 
to treatment which would only modify the course of eczema, ecthyma,, etc. 

Prognosis. — The disease may end spontaneously in about two weeks, but 
may be perpetuated for a longer time by auto-inoculations in neglected cases. 
It is quickly cured by treatment. 

Treatment. — Sterilizing the affected skin with any mild and unirritating 
parasiticide will cure the disease in a few days. Nothing is better than a one 
to five per cent, ointment of ammoniated mercury rubbed into the parts three 
times a day. When the crusts become loosened they can be washed off with 
soap and water. Almost equally effective and sometimes preferable, if the 
surface involved is considerable, are ointments containing naphthol, ten to 
fifteen grains; resorcin, ten to twenty grains, or boric acid, thirty grains to an 
ounce. If the mucous surfaces are affected, a saturated aqueous solution of 
boric acid (filtered) may be used as a wash, twice daily or oftener. Internal 
remedies may be given as indicated, but the very contagious nature of the dis- 
ease forbids reliance on them alone. See Ant. crud., Ant. tart., Gal. sulph., 
Cicuta, Kali bichrom., Lye, Nat. sulph., -Pic. acid, Sil., Thuja, Viola. 



ECTHYMA 

Definition. — An inflammation of the skin characterized by the devel- 
opment of one or many large, discrete, flat pustules, situated on an indu- 
rated base surrounded by an intensely hyperaemic areola, and drying into 
dark, bulky, firmly attached crusts, underneath which may be found a 
smaller spot of erosion or ulceration. 

Ecthyma, while no longer standing for a distinct disease, represents a clin- 
ical type of cutaneous inflammation which, like impetigo contagiosa, may 
follow pus inoculation under favoring conditions of the skin, or characterize 
some lesions of a definite affection, such, for instance, as the ecthymaform 
pustules of syphilis and variola. 

Symptoms.— The eruption begins as reddish or yellowish pea-sized or 
slightly smaller pustules, which enlarge and may reach the size of a dime to a 
quarter of a dollar. They arise from a distinctly circumscribed inflammatory 
base, bordered by a varying area of congestion, the color from which gradually 
fades into the surrounding skin. The intensity of the process directly under 
the centre of the pustule may result in superficial destruction of tissue and the 
formation of a small, shallow, circular, pit-like ulcer, and on removal of the 
crust is found bathed with a purulent, often sanious product. If this secretion 
is carefully wiped away the floor of the ulcer will be found to consist of reddish 
or grayish granulations. In proportion to the product of this pustular process 
will be the size of the resulting crusts, which are usually bulky, rough, firm, 
brownish or blackish colored from admixture of blood with sometimes lighter 
or yellowish edges. Individual lesions usually pursue an acute course covering 
ten or twenty days, and only a few lesions may appear: in other cases, new 





A^^^rJ 


■ 






j 


%?j£ 








^H 




0f 




* Mm 






-- ■ 


* 


* 

^J 

^^b 


t« '■ 











Fig. 97.— ECTHYMA 

Patient, a plethoric German of thirty-one, living in poor dirty surroundings. 
Duration, six weeks. Both legs were involved. The lesions consisted of about 
forty large flat discrete pustules, some reaching the size of a quarter dollar, and ap- 
pearing in crops; an individual lesion averaging two weeks in duration. Thick firm 
brownish-black crusts formed when the pustules broke or were ruptured. On re- 
moval of the crusts a superficial ulcer was uncovered, showing a mixed purulent and 
sanious discharge. A marked areola of redness surrounded each lesion, and there 
was a slight amount of itching. Mezereum, sixth centesimal, was given before the 
patient came to the clinic; afterwards under the use of psorinum, sixth centesimal, 
and daily baths of the saturated solution of hyposulphite of soda, the patient recov- 
ered in three weeks. 




Fig. 98— ECTHYMA 
Same subject as Fig. 97, showing inner aspect of left leg. 



ECTHYMA aa5 

pustules continue to arise every few days and the disease may be prolonged for 
months. Pigmentation may show the site of former pustules and rarely may 
be permanent. In colored people the opposite condition of partial or complete 
absence of normal pigmentation has been observed to follow the disease. The 
eruption is commonly located on the lower extremities in adults of either sex, 
but it may occur upon any portion of the body and at any age. Occasionally 
an outbreak is preceded by slight fever, and during the formative stage of the 
lesions, moderate local soreness, heat and burning pain may be felt, while itch- 
ing is very slight or only noticed during the healing process. 

Etiology and Pathology. — Ecthyma occurs exclusively in the debilitated, 
cachectic, improperly fed, poorly nourished, or among those dwelling amid 
unsanitary surroundings. Under the influence of such predisposing factors 
slight traumatisms,' bites of insects-, scratch marks made in effort to relieve 
itching from whatever source, easily become infected with pyogenic cocci, while 
filth and neglect contribute to aggravate the grade of pustulation and render 
its product more inoculable and auto-inoculable. So far as known, the essen- 
tial cause is usually the streptococcus acting on tissues probably deprived for 
the time being of their normal resisting power. Pathologically the pustule of 
ecthyma does not differ from the similar lesion of impetigo or eczema, except 
in its deeper seat and lower grade of inflammation. It usually involves the 
entire thickness of the epidermis and the papillary layer of the corium, leav- 
ing at its termination only temporary or scarcely noticeable scarring. Occa- 
sionally the deeper parts of the corium are involved in the destruction process 
and the resulting cicatrices are permanent. 

Diagnosis. — Ecthyma is to be distinguished from ecthymaform lesions of 
other distinct forms of cutaneous disease. This can usually be done without 
difficulty by noting the presence of diagnostic signs of the several affections. 
Thus smallpox may produce ecthymaform pustules, but the different onset, 
course and presence of more characteristic lesions would determine the exist- 
ence of that disease. The flat pustular syphilide would nearly always be 
accompanied with a history or some other signs of syphilis. Its pustules are 
less inflammatory, without the extensive, hard and bright red base of ecthyma ; 
it is sluggish and slower in course, the ulcer underneath larger, deeper, more 
. sharply defined and its thicker secretion dries into greenish crusts, often conical 
or oyster-shell-like in shape. The pustules of impetigo and impetigo con- 
tagiosa may be differentiated from ecthyma by their superficial situation, ab- 
sence of indurated base and ulceration, yellowish crusts, and their occurrence 
in childhood rather than like ecthyma in adult life. Other points of difference 
may be found under diagnosis of the two first named diseases, respectively. 

Prognosis. — Ecthyma is always curable within a short time under proper 
management. 

Treatment. — This is essentially causal and hygienic. Predisposing and 
contributing factors should be removed so far as possible, and the patient's 
general health built up by suitable diet and healthful surroundings, includ- 
ing a daily bath with soap and water. If the crusts are not readily removed 



336 SYCOSIS 

by bathing, they may be softened previously with vaseline or any simple fat or 
oil, and after the bath the same application will afford protection to the parts. 
In the more severe cases a mild antiseptic ointment will be fonnd of service. 
Boric acid, twenty to forty grains; resorcin, fifteen to thirty grains; calomel, 
five to fifteen grains; or haphihol, ten to twenty grains to an ounce of fresh 
lard, are suitable for this purpose. When the eruption is extensive baths made 
alkaline with bicarbonate of soda or ammonia or saline with common salt may 
be used. A. P. Sherwin reports that a recent epidemic of this disease occurring 
in an institution was successfully stopped by the local use of collodion. The 
editor has used adrenalin 1 : 1000 in his hospital practice as a local applica- 
tion with good results. In some cases, where the crusts are dry, adherent, and 
suppuration is apparently inactive underneath, no local measures other than 
cleanliness need be employed, the crusts falling off of their own accord as heal- 
ing is completed beneath, under the influence of improved nutrition and an 
indicated drug. The latter should always be given, and in many cases will 
effect a cure in spite of unfavorable environments. See indications for Argen. 
nit., Kali bichrom., Merc, Merc, cor., Merc, biniod., Mur. acid, Plios., Psor., 
Secale, Sil., Thuja. 

SYCOSIS 

("Non-parasitic" sycosis; Mentagra; Folliculitis barba?; Sycosis barbce, etc.) 

Definition. — An acute or chronic folliculitis of the hairy parts 
of the face, or rarely of other regions provided with large hairs, due 
to the microbic infection and characterized by the presence of papules, 
pustules and crusts perforated by hairs. 

This affection was formerly termed non-parasitic in distinction to inflam- 
mation of the hair follicles due to the presence of the ringworm fungus, 
described in this work as tinea barbae and to which the term sycosis should no 
longer apply. It is now held as a result of modern research that sycosis is 
parasitic in origin, probably from the interfollicular invasion of pus organ- 
isms, and while to a certain extent inoculable and auto-inoculable is not 
clinically a contagious disease. 

Symptoms. — The disease varies greatly in extent and degree, is commonly 
limited to the region of the beard of men, but may occur in the eyebrows, axilla? 
and pubic regions of either sex. Away from the bearded portion of the face it 
is usually milder in form. Beginning on one or more parts of the face, upper 
lip, chin or cheeks, the lesions appear usually as acneform, conical or flat 
papules or nodules, soon becoming pustules and situated about the hairs. They 
may be few or many, scattered or near together, but generally increase gradually 
in number. When seated on the upper lip (occasionally involving the hair 
follicles in the nostrils) there is often a history of a previous nasal catarrh; 
then it often begins acutely with eczematous inflammation attended with heat, 
burning and itching sensations. As the catarrhal inflammation of the sur- 




Fig. 99.— SYCOSIS 

FRONT VIEW 




Fig. 100.— SYCOSIS 

SIDE VIEW OF FIG. 99 

Patient, a young man of twenty. Duration of disease, three weeks. Located 
on the bearded region and consisted of papules, pustules and crusts pierced by hairs. 
Erythema and itching pronounced. No microscopic or etiological evidences of ring- 
worm. Treated with hepar sulphur, third decimal, and various mercurial ointments 
locally for six weeks. Although much improved, the cure was perfected by six X-ray 
treatments, varying from five to fifteen minutes in duration at distances varying 
from twelve to six inches from the tube. 



sycosis :«7 

face subsides, pustules remain whose seat at the pilary follicle is proved by 
the penetration of each by a hair filament. Whatever the mode of onset 
new follicles are apt to be successively involved, and the skin may exhibit at 
times a mingling of pin-head to pea-sized or larger papules, pustules or tuber- 
cles and crusts in various stages of evolution and involution, or the eruption 
may appear in crops, and as involution of some lesions go on, a new crop 
arises. The discrete, closely aggregated lesions of a visible patch of sycosis 
may present a resemblance to a fig, from whence the disease derives its name. 
The hair which at first is firmly seated in the follicle and cannot be 
extracted without pain, as suppuration in and about the follicle becomes active, 
can be easily and almost painlessly plucked ; the hair is reproduced unless the 
follicle is destroyed by the suppurative process when the hair falls spontane- 
ously, followed by cicatrization and permanent loss of hair. In long-standing 
cases the hair is apt to be thin and lacking in vigor. In moderate cases, 
the pustular secretion dries into small separate crusts marked by the cen- 
trally situated hair; in severe cases the close aggregation of lesions produces 
an almost continuous infiltration covered more or less with purulent crusts, 
which on removal may reveal a weeping surface and the hairs left implanted, 
as it were, in shallow pits resulting from the loss of their root sheaths. After 
months or years of the disease the hair is thinned, but distinct alopecia is rare 
and, if present, is accompanied with equally rare and resulting scars. Unar- 
rested by the treatment, a sycosis becomes chronic in course, gradually invading 
new follicles until the whole region of the beard may be more or less involved, 
but the disease never extends on to the non-hairy parts of the face. Tn 
these chronic cases, which have been known to last for twenty to thirty years, 
symmetry of involvement becomes a feature of the disease and one side of the 
face may be a close counterpart of the other. Atypical lesions may appear 
from time to time and change the clinical picture. Furuncles; soft, fluctuat- 
ing, finger-nail-sized swellings, which discharge pus through openings left 
by extraction of hairs on their surface; vegetations, and eczema of adjacent 
parts, or near by, are some of the additional lesions occasionally observed as 
aggravations of the morbid process. In other advanced cases the inflamma- 
tion subsides to a considerable degree, leaving a persistent redness, somewhat 
covered by whitish scales and broken by the appearance of an occasional 
papule or pustule; or, again, a condition resembling eczema may develop in 
the affected skin, the papules and pustules arising in infiltrated tissue without 
being elevated or very easily distinguished, form scales and crusts. Some 
degree of eczema is nearly always present in long-standing cases. Excep- 
tionally a sycosis may preserve its typical features throughout a long course 
of aggravations and ameliorations. One case under the writer's observation, 
in which the inflammation was confined to the chin, remained follicular in form 
during a course of six years; at short periods apparently disappearing to break 
forth again on slight neglect of shaving or other means bf prevention. At the 
acme of intensity a marked resemblance, over a small area, to carbuncle was 
once or twice observed. 



338 SYCOSIS 

Lupoid sycosis is a term used to designate a rare condition beginning in 
the skin of the beard, and which is destructive and scar-producing to a much 
greater degree than ordinary sycosis, and resembles somewhat in its resulting 
effects lupus erythematosus or superficial lupus vulgaris. This form was 
briefly mentioned by Milton over thirty years ago, who gave to it the name 
lupoid sycosis, and Eobinson described its anatomy from a case under his 
observation nearly twenty years ago. In more recent years Brocq has described 
it under sycosis lupoide, and Unna as ulerythema sycosiforme. The latter 
classes it among "regressive disturbances of nutrition," and particularly, as the 
name signifies, a scar-producing erythema. The process consists of a primary 
erythema, an intermediate stage of infiltration, and a third stage of complete 
atrophic destruction of the skin including the sebaceous glands and hair folli- 
cles of the affected parts, leaving a smooth, white, slightly depressed cicatricial 
surface. According to Unna; it begins in the beard or temple as a well-defined 
erythematous spot on which vesicles, scales and crusts form. It spreads ser- 
piginously in the line of the beard, slowly and persistently, and is little 
influenced by treatment. The appearance of pustules may make it look like 
a coccogenic sycosis, but the atrophic scarring is never the result of suppura- 
tion. Eobinson says the perifollicular lesions may be papular, vesicular or 
pustular, and as long as the disease is progressing pustular lesions are found 
at the periphery. In the only case of my own, which began in the beard near 
the central part of the cheek, and in the five years of its duration had pro- 
gressively extended downward to the side of the chin, minute papules, vesicles 
and scales were discernible in the narrow elevated erythematous margin, but 
at no time was I able to discover the presence of pustules. The disease may 
attack the scalp, eyelashes and eyebrows. This affection is evidently not 
related to ordinary sycosis, and probably is entitled to the distinctive name 
given to it by Unna. 

Sycosis of the scalp and other parts of the body provided with large hairs 
is less common than on the face, and is nearly always associated with eczema- 
tons inflammation of the skin of those regions. Uncomplicated sycosis very 
rarely causes swelling of the lymphatic glands, and deep-seated nodules,, com- 
mon to ringworm of the beard, are never seen. 

Etiology and Pathology. — Sycosis occurs chiefly in males after puberty, 
though analogous pustular folliculitis of other parts may occur in adults 
of both sexes. It appears to be dependent on no special condition of the skin, 
health or mode of life. The same influences which render the skin vulnerable 
to pustular eczema and other suppurative processes may be also the predisposing 
causes of sycosis. These may be external, such as mechanical, chemical or 
thermal factors which derange the local nutrition ; or internal, from retention 
of waste and other products in the tissues due to the defective elimination 
or over-production, etc. Under these favoring conditions of the surface tissues 
an invasion of the pilo-sebaceous crypts by pus cocci excites inflammation in 
and about the follicle. To susceptible skins, sycosis may be contagious and 
communicated in various ways, such as by shaving, the common use of combs, 
towels, sofa pillows, reclining chairs, etc., in hotels and public places. 



SYCOSIS 889 

According to Robinson, who has examined the diseased skin from a living 
subject, the pathological changes met with are the same as in ordinary vascular 
connective tissue inflammation due to pus cocci. The perifolliculitis and folli- 
culitis produce a transudation of serum which penetrates the hair follicle, pus 
forms, and with the increase of this sero-purulent exudation, softening and rup- 
ture of the hair sheaths occur, with infiltration of the root and separation 
of the latter from its broken sheaths, thus loosening the hair, which may then 
act as a mechanical irritant. Before the hair falls out pus may reach the 
surface between the shaft and follicle sheath, or more often by a break in the 
epidermis near the hair. Though the follicle sheaths and perifollicular tissues 
are more or less destroyed, the papillae escape, as a rule, and loss of hair is 
therefore temporary in most cases. 

Diagnosis. — Other pustular inflammations of the skin may show an occa- 
sional pustule pierced by a hair, but a preponderance of the lesions, limited to 
the hairy surfaces, especially the beard, always favors the existence of sycosis. 
Eczema, tinea barbae, the pustular syphilide, and acne vulgaris are the only 
diseases likely to be confounded with sycosis. 

Eczema differs from sycosis in being seldom confined to the hairy region, 
in originating in all parts of the skin, at first more superficially seated than 
the latter and usually less intense ; it may be attended with a continuous exuda- 
tion, forming more extensive crusts which are not limited to the pilary follicles. 
Moreover, eczema is accompanied with marked itching. The two diseases may 
coexist,, either being primary in order of occurrence; or an eczema may clear 
up after a time between the follicles, leaving the latter inflamed, practically 
terminating in a sycosis. Tinea barbce may develop pvistular lesions penetrated 
by hairs, but unlike sycosis it often begins in scaly circinate, well-defined 
lesions or patches, and when the hair and follicles are invaded, the broken-off, 
stubby and early loosened hairs, the characteristic lumpy, nodular, non-sup- 
purative swellings, multiple foci and more acute course are distinctive of ring- 
worm, and should lead, in case of doubt, to a microscopic examination for the 
fungus of the latter. "A pustular syphilide will always show evidences of ulcera- 
tion on removal of the crusts, is usually attended with other concomitant symp- 
toms of syphilis, and is rarely confined to the follicles or to the beard or sur- 
faces supplied with large hairs. Sycosis lacks these peculiarities. Acne vulgaris 
lesions usually begin before adult life, are not confined to the hairy parts, but 
occur on the nose, forehead, cheeks, etc. They are often marked with comedones 
rather than pierced through the centre by a hair. 

The rare affection known as lupoid sycosis may be recognized by its limita- 
tion to the hairy parts, its well-defined, slow, progressive extension, superficial 
but destructive character and resistance to treatment. 

Prognosis. — Sycosis is never dangerous to life, but is frequently obstinate 
to treatment and apt to recur. Still it is probably always curable under judi- 
cious management. The larger the lesions the greater the liability to scarring: 
and consequent thinning of the beard. 

Treatment. — While sycosis is undoubtedly a local infectious, suppurative 



340 SYCOSIS 

process, it is not to be forgotten that predisposing influences first prepared a 
suitable soil for its development. These factors, therefore, demand first con- 
sideration in treatment. Disturbed functions,' especially of the assimilative 
and eliminative organs, should be corrected by dietetic and other methods of 
hygiene which will suggest themselves as appropriate and possible of applica- 
tion in individual cases. With the improved tone of the tissues from physio- 
logical means and drug remedies to be mentioned later, local treatment will 
be most effective. 

Radiotherapy is the best single local treatment for all cases of this disease. 
The technique is the same as described under acne, with the possible exception 
that a harder tube is more desirable. Eight exposures usually suffice ; the aim 
being to produce a slight erythema and falling of the hair. Usually this reac- 
tion disappears in a few weeks. The editor has followed this procedure in six 
cases, including one of lupoid sycosis, with uniform good results. In very mild 
formsTthe unipolar X-ray tube has been efficacious. 

Further local treatment may be aimed to remove the crusts, and the loosened 
and irritating hairs, to maintain as absolute cleanliness as is possible without 
irritating the parts, and to give protection to the affected surface. Crusts may 
be softened with applications of simple oil or fat; and then removed by washing 
with soap and hot water, or still better hot borax water. Shaving is the best 
method of treating the hairs, and is only painful the first few times; but 
patients object to it both on account of the pain and the more apparent expo- 
sure of the surface after shaving. If refused the beard must be cut short and 
the loosened hairs plucked out with epilation forceps over a small area every 
day or two. Nearly absolute cleanliness may be kept up by washing as sug- 
gested above, or with a hot saturated solution of boric acid, dilute peroxide of 
hydrogen solution, corrosive sublimate or creolin soap, followed in mild cases 
during the day by dusting over the affected surface with impalpable boric acid 
powder, and at night by an application of a ten per cent, ointment of the 
same, or salicylic acid fifteen grains to an ounce of oxide of zinc ointment. 
In more severe cases ointments may be used containing any of the following : 
Naphthol, fifteen to twenty-five grains; resorcin, twenty to thirty grains; 
ammoniated mercury, ten to twenty grains; calomel, thirty grains; corrosive 
sublimate, one grain; europhen, fifteen to twenty grains, or sulphur, sixty 
grains to an ounce of fresh lard or vaseline. In suitable strength these applica- 
tions are antiseptic and protective in effect, without producing irritation, but 
the strength must vary somewhat with the extent of the affected skin and the 
degree of sensitiveness, the rule being never to excite further inflammation. As 
in other siirface diseases of the face applications conspicuous in color or odor 
are to be avoided if possible, and therefore are not mentioned here, though some 
such as ichthyol and iodoform are sometimes of special value. Occasionally 
acute cases are seen in which water containing bicarbonate or biborate of soda 
continuously applied is serviceable in reducing the more acute inflammation, 
after which the local methods adapted for mild or severe cases may be em- 
ployed as needed. In long-standing, obstinate cases with much infiltration 



FURUNCULUS 341 

a local pathogenetic effect may be obtained by painting a small area at a 
time with liquor potasses, as suggested by Crocker. This is washed off in half 
a niinute, and zinc or other mild protective ointment applied. Jackson speaks 
of the following combination as effective in some cases after other applications 
have failed : 

R. Hydrarg. sulph. rubri gr. 7. 

Sulph. sublimat 3 3. 

Adipis 5 li- 

01. bergamot q. s. 

M. Sig. — To be kept on constantly. 

In all cases of sycosis the ultimate cure depends on a continuous persever- 
ance with treatment even beyond the period of apparent cure, else a relapse 
is very liable to occur. This applies also to internal remedies, which are all- 
important and to be selected on careful individualization. See indications 
for Arsen. iod., Graph.,- Hepar, Kali brom., K. mur., Merc, M. biniod., Nat. 
sulph., Viola. 

FURUNCULUS 

(Furuncle; Bails.) 

Definition. — An acute, circumscribed inflammation of one or more 
hair follicles, sebaceous or sweat glands and adjacent tissue, characterized 
by the formation of a cutaneous or subcutaneous nodular infiltration, fol- 
lowed by suppuration, necrosis, discharge, and a resulting scar. 

Symptoms. — The familiar affection known as "boils" may occur in a 
single lesion or in crops of two or more without any tendency to group, and 
when crop after crop succeed each other, lasting for weeks and months, "furun- 
culosis" is said to exist. A furuncle lesion shows first on the skin as a small 
reddish point or papule, generally pierced by a rudimentary hair and accom- 
panied with slight burning or itching sensations. Soon induration can 
be felt, which in one or two days increases to a variably sized nodule, elevating 
the skin, and in the centre marked by a small vesicle or pustule, often sur- 
rounded by a red areola. Barely, at this stage, the process is arrested, con- 
stituting the "blind boil," the pustule dries up and resolution takes place in 
the nodular mass. Commonly the inflammation increases in intensity and 
extent until the tuberosity reaches the size of a hazel-nut to a small walnut, 
well imbedded in or under the skin, or projected more or less above the surface ; 
the area of redness meanwhile enlarges, and assumes a darker or purplish color 
owing to venous obstruction ; the parts and adjacent skin become exquisitely 
sensitive to pressure, while sensations of heat throbbing and tension are fre- 
quently felt to a painful degree. If the central pustule is accidentally or pur- 
posely opened on the third to fifth day a few drops of blood and pus escape, giv- 
ing slight relief; left to itself, by the end of a week spontaneous rupture is 



342 FURUNCULUS 

likely to occur, followed with a free discharge of pus, usually leaving a ragged 
craterif orm opening in the skin, and exposing beneath the central necrotic pus- 
soaked mass called the "core." This is usually found to be firmly attached 
beneath, but after a few days it becomes loosened by further suppuration at 
its base, and is then expelled spontaneously or can be easily lifted out. Occa- 
sionally the necrotic core is absent and a free discharge of semi-liquid pus 
completes the evolution of a furuncle. Either form of evacuation gives much 
relief. The reparative process takes place gradually by granulation as the 
drainage is completed, and finally closes the skin with a purplish or violaceous 
maculation, which color fades away in a few weeks or months, leaving a small 
permanent cicatrix. 

The duration of a single furuncle varies from one to four weeks; rarely 
the process may be completed in a shorter period or may require a longer time. 
The duration of an attack is equally elastic, depending on the rapidity of the 
morbid process and the number of successive crops, but is not infrequently pro- 
longed for months. 

Boils may occur on any part of the body, but are most often located about 
the neck, ears,, buttocks, ano-genital region, extremities, and less frequently 
on the face, hands, feet and other parts. Neighboring lymphatic glands are 
often sympathetically swollen, and in chronic furunculosis constitutional symp- 
toms may appear early or later, and of variable degree, such as pyrexia, anaemia, 
nervous depression, loss of appetite, and rarely hectic fever and marked cachexia 
may develop. Furuncles sometimes occur as complications or sequela? of other 
affections, notably in eczema, scabies and diabetes. 

Etiology and Pathology. — No single state of the system predisposes to 
furuncles. Depraved nutrition from various conditions, such as the lithaemic, 
neurasthenic, anaemic, diabetic, ursemic, septicaemic, may create the tendency 
to boils, but the affection also occurs in persons of more than average vigor. 
Here the departure from a normal state of the tissues may be one of excess of 
nutrition or lack of elimination, rendering the skin in either case vulnerable 
to factors which excite inflammation. The greater frequency of boils in the 
spring is probably due more to a lack of any change in diet with the advent 
of warm weather, together with the frequent alternation in the activity of the 
skin under the influence of the latter, than to mere external factors. Co-oper- 
ating with any of these systemic perversions may be any one of all sorts of 
local agents which inflict injury on the skin. Among these may be named im- 
petigo lesions (TJnna), excoriations made with the finger-nails during the 
course of eczema, pediculosis, scabies and other pustular or pruritic affections, 
long-continued frictions, pressure or abrasions from collar buttons, hard saddles 
or bench, occupations which expose the skin to irritating or poisonous sub- 
stances such as happen to dyers, tanners, butchers, scavengers, etc., drug erup- 
tions, vesicant applications, poultices and simple ointments which separate 
or soften the epidermis and open the follicles. These or similar factors facili- 
tate the entrance into the follicles of the staphylococcus pyogenes aureus, which 
is usually the efficient cause of furuncular inflammation, and the product 



FUIUJNCULUS M ' 6 

from which has been shown to be inoculable and auto-inoculable under favoring 
conditions of the skin. 

The pathology of furunculus is not peculiar to this disease, except in the 
seat of the morbid process. Unna maintains that, the common origin of a 
furuncle is from an impetigo lesion which meets with such resistance outwardly 
in the horny layer or from rapid pus formation as to force an extension down- 
wards until it penetrates beneath the epidermis, or the pus cocci penetrate 
deeper into a lanugo hair follicle which runs through the pustule. Whatever 
the mode of entrance of the infection may be, if the soil is favorable a suppura- 
tive perifolliculitis and folliculitis is established, which, owing to its imprison- 
ment under the epidermis, gives rise to most of the symptoms peculiar to boils. 
If the inflammatory exudation is intense enough, around the follicle central 
necrosis occurs, and the "core" thus produced remains moist, puriform and 
yellow because it is held in a pus-producing pocket. The process of repair is 
not unlike that following loss of tissue from other suppurating inflammations. 

Diagnosis. — As in the case of ordinary nettle-rash, so the patient often 
makes a correct diagnosis of boils without the aid of a physician. It is suffi- 
cient to mention that boils have been mistaken for suppurating buboes. Differ- 
ences in mode of occurrence and evolution easily distinguish the latter. 
Hydradenitis begins by the formation of one or more painless, subcutaneous, 
shot-like nodules, and when they slowly reach their acme exhibit only slight 
inflammation, elevation and tenderness as compared with furuncles. Car- 
buncle would' only be mistaken for furuncle in the very early stage. A few 
hours' observation would show the more extensive infiltration, and later, the 
appearance of multiple points or breaks in the skin which help to clearly charac- 
terize the former. 

Prognosis. — Simple, uncomplicated furuncle may give the patient little 
trouble, and run a short course under proper treatment. As a complication or 
sequela of other affections the probabilities would relate chiefly to the primary 
disease. Boils irritated by a continuance of occupation or from other sources 
may lead to inflammation of the lymphatic glands and possibly embolism or 
purulent infection of internal organs such as the lungs or brain. The danger 
of the latter from furuncle of the face is always to be kept in mind as a 
possibility. 

Treatment. — -The general or local causes of furuncle should be ascertained 
in each case on the lines indicated under etiology, and so far as practicable 
removed. Even when apparently leading a healthful mode of life, a victim 
of boil may be often benefited by temporary change of diet, habits, residence, 
occupation, etc. By physiological methods much can be done to mend systemic 
defects and remove contributing causes. In many cases, however, the necessary 
physiological means cannot or will not be carried out, and the chief reliance 
has to be placed on the employment of pathogenetic and local methods. Every 
furuncle may be considered as a possible source of further infection, as well 
as likely to produce a permanent defacement of the skin, and the object of local 
treatment is to reduce these tendencies to a minimum. Boils from start to 



3U CARBUNCULUS 

finish have lost their once reputed value as conservators of health, and may 
always be arrested early in their evolution with advantage to the patient. If 
a hair is found protruding from the centre of a boil it may be pulled out and 
the surface well painted with iodine, allowed to dry and nosophen powder well 
rubbed in. This will often abort the furuncular process. Still more effective 
in most cases is the continuous application of a two to six per cent, solution of 
creolin in glycerine, or in conspicuous locations it can be kept on at night and 
nosophen dusted over the lesion during the day; even rubbing the solution 
on and about a furuncle four or five times a day has served to arrest its develop- 
ment at an early stage. A few layers of gauze saturated with this solution 
are a most excellent dressing throughout the later stages where too far advanced 
for abortive treatment to be successful. In the author's hands this application 
has proved so effective that other local measures are seldom used. 

Buckley speaks rightly of the abortive and other actions of the following 
combination applied on absorbent cotton : 

R. Acidi carbolici gr. 5-10. 

Extr. ergotae fl'd 3 1-2. 

Pulvis amyli 5 2. 

Zinci oxidi, 

Unquent aquae rosae aa 5 2. M. 

Poulticing should be discarded in the treatment of boils, as it promotes 
growth of the cocci, and incision should not be made at any stage unless for 
some special reason or to avert impending danger. Neither should a boil be 
squeezed to remove the core, as bruising the surrounding abscess wall favors a 
fresh extension of suppuration. In most cases the antiparasitic and protective 
local means before mentioned are all that is required, the indicated drug at 
the same time aiding greatly in effecting a removal of the systemic predispo- 
sition and consequent cure of the local manifestations. The internal remedy 
may be chosen on well-known indications as furnished by such drugs as Anthra- 
cinum, Apis, Am., Bell., Gal. sulph., Crotal., Hepar, Kali orom., Led., Lye, 
Nat. mur., Phos. acid, Phyto., Pic. acid. Rhus. Secale. Sil.. Sul., Vespa, Vipera. 



CARBUNCULUS 

(Anthrax simplex; Anthrax benigna : Carbuncle.) 

Definition. — An acute, circumscribed cutaneous and subcutaneous in- 
flammation, characterized by a broader induration than occurs in furuncle, 
undermining of the integument and the appearance of several pustules on 
the deep red or dusky surface, finally terminating in death of the deeper 
parts by sloughing, and often of the superficial parts by gangrene. 

Symptoms. — Constitutional disturbances usually precede carbuncle such 
as chill, fever, languor and, when situated on the head or unusuallv extensive, 



CAKBUNCULUS B46 

prostration may become alarming in degree. There is commonly felt a burning, 
tensive pain at the site of the beginning lesion, which consists of a deep, flattish, 
hard swelling covered by the reddened skin, soon becoming darker tinted. 
.From the size of a boil or larger the infiltration may spread laterally to the 
diameter of a half-dollar up to the palm of the hand, rarely larger. This pre- 
sents at the end of a week or ten days the appearance of a flatly convex hard 
tumor, of a livid color, gradually merging into the surrounding skin, with its 
surface studded with several or numerous pustules or circular openings in 
the skin which mark the site of pustules of a few days before. Through 
these apertures a sanious pus indolently exudes, and the pus-soaked sloughs 
can be seen beneath, representing at this time the most pathognomonic stage 
of carbuncle. As the process goes slowly on the slough breaks down and is dis- 
charged through the enlarged openings in the skin, or the latter gives way with 
the slough, is thrown off in large parts or en masse, leaving a sharply cut crateri- 
form ulcer with uneven floor and overhanging edges. The process of repair 
is the same as after furunculus, by new granulation tissue and closure by cica- 
tricial tissue. The scar often remains a violet tint for some time, and then 
fades to a whitish indelible and sometimes puckered spot. 

The duration of carbuncle varies from two to six weeks, according to the 
size and location of the lesion, and age and general condition of the patient. 
All these factors also largely determine the degree of attendant systemic dis- 
turbance. Under favorable conditions these may be slight, but in asthenic 
cases where there is considerable sloughing of tissue there are usually rigors 
and fever of a septic type, which in dangerous cases may become typhoidal in 
form; even without extensive lesion the local process may be of a low grade. 
Sometimes at its height the supra-imposed skin becomes bluish-black, and dries 
into a firm gangrenous eschar, more completely imprisoning the sloughing mass 
beneath until the former separates in the usual way; occasionally, on the gan- 
grenous surface, a blood blister may form, or the skin undergo another change 
into a soft, gangrenous mass. Again, under some unfavorable condition, the 
process may continue to extend at the periphery; islands of necrotic tissue fo"rm, 
bridged with soft purplish skin and undermined by exhausting suppuration. 
The carbuncle lesion is usually single, and most often located on the back of 
the neck, shoulders., back, buttocks and lateral aspects of the thighs. It is 
especially dangerous, but fortunately rare, on the scalp, face or abdomen. 

Etiology asd Pathology. — The predisposing and co-operating causes of 
carbuncle are practically the same as have been stated in the etiology of furun- 
cle. Pathologically it is a similar but deeper and more extensive inflammation, 
or in nature an agglomerate furunculus, and probably due to an invasion of the 
same staphylococcus. Whether these organisms are purely etiological or partly 
accidental, in relation to a primary infiltration of the tissues originating from 
constitutional states or depression, is not definitely known, as early histological 
investigation of the morbid process has not been made. Unna holds the opin- 
ion that there must be a special organism for carbuncle, that the secondary 
suppuration only favors the attack of pyococci at that time. This also may 



340 CARBUNCULUS 

afford an explanation of the fact that inoculation of the skin of another 
person with the pus from a carbuncle has produced furuncle. The most plausi- 
ble explanation of the pathology of this disease, based on the investigations of 
J. C. Warren and others" is, that it begins like furuncle in the follicles or 
glands, but in those which are situated in thick and outwardly resisting skin, 
and, therefore, the process spreads in the direction of least resistance, down- 
wards deeply into the fat of the subcutaneous tissue, there spreads and again 
rises along the fat columns (columnae adiposae), infiltrates the cutis and crowds 
the papilla? with pus, which finally oozes to the surface through the under- 
mined epidermis. Thus is produced the peculiar clinical picture of carbuncle, 
as a subcutaneous and cutaneous abscess with currents of pus forced up be- 
tween the fibrous bundles of the cutis into the papilla?, and riddling the epi- 
dermis before the necrotic derma, with its relatively intact fibrous frame- 
work, has sloughed. This mode of evolution of the carbuncle largely beneath 
the thiclc and unyielding fibrous tissue accounts probably for the classical 
symptoms of the disease rather than any peculiarity in the inflammatory 7 
process. 

Diagnosis. — The diagnostic symptoms of carbuncle are its single lesion, 
location in the thicker portions of the skin (back of the neck, shoulders, etc.), 
deep, flat, board-like swelling covered by the congested skin, and later the 
appearance centrally of isolated pustules or necrotic points, the accompanying 
burning sensation and systemic disturbances. These will at once or within 
a few days clearly distinguish it from all other affections. The larger size 
and multiple openings differentiate it from furuncle. Occurring on the face 
it might be mistaken for erysipelas, but the oedema of the latter is never of 
board-like hardness or followed hy the development of necrotic plugs as in 
carbuncle. 

Prognosis. — A forecast of this affection must always include the influence 
of predisposing factors. In grave diseases like Brightfs and diabetes, carbuncle 
is always a serious complication ; and its occurrence in the aged or in persons 
of reduced vitality from any cause is unfavorable. Location on the scalp, 
face or abdomen adds to the danger. Nevertheless recovery may be looked 
for in the great majority of cases under appropriate treatment. 

Treatment. — Carbuncles rarely occur in the vigorous; hence supporting 
measures will nearly always be in order, and may have a direct relation to some 
antecedent affection, as, for instance;, the diet in diabetes or kidney affections. 
In old people especially, simple, easily digested and sustaining food should be 
taken in small quantity often enough to support the prospective tax and drain 
on the system. Best in bed is wise in all severe cases. With physiological 
treatment ranks in importance the internal remedy, which must be selected on 
the indications and stage of the morbid process, as will be pointed out further 
on. Antipyretics, so-called, should not be given internally to reduce fever. 
The only safe way to reduce temperature is by local antisepsis, which at the 
same time meets the indications for other local needs in most cases. Locallv, 
carbuncles may be treated the same as boils, with continuous but frequently 



ANTHRAX 8W 

repeated applications of creotin three to ten per cent, in glycerine. Early 
treatment in this way will often abort a carbuncle or greatly modify its course, 
and since the employment of this preparation the author has not felt the need 
of using injections of a saturated solution of carbolic acid, incision or other 
surgical method. In every case it has aborted or greatly modified the usual 
course of the morbid process, even when the lesion has been broad and threaten- 
ing. Eubber tissue or oiled silk can be placed over the gauze saturated with 
the solution when needed to protect the clothing. Buckley's formula named 
in the* treatment of boils is also recommended for carbuncle, employed in 
the same manner, and repeated two or three times in the twenty-four hours. 
Other and older methods of local treatment possess no advantages over the 
antiseptic, and each has some objectionable feature. Poulticing is harmful, 
as it tends to favor the growth of pyogenic cocci and extend the infected area. 
In the latter stages of neglected cases, when there is considerable constitutional 
disturbance or local pain, complete evacuation of the abscess cavity (under 
partial anaesthesia) with the curette, followed by antiseptic and protective 
dressing, gives great relief and may be, therefore, occasionally demanded. The 
radical operation of excision of the entire carbuncle at one time, as advocated 
by Eeidel and others, might be justified in rare cases by the location of the 
infiltration in dangerous proximity to some vital or important structure. It 
is then a strictly surgical procedure, and should be performed only under 
the precautions used in the removal of subcutaneous tumors. 

Only those who have witnessed the effect of internal medication on the 
course of carbuncles can appreciate the value of indicated remedies. The 
author has had opportunity to observe treatment both with and without indi- 
cated drugs, and can affirm his belief in the equal if not greater importance 
of the latter in comparison with external methods alone. See especially indi- 
cations for Anthracinum, Apis, Arsen., Bell., Cal. sulph., Carbo veg., Crotal., 
Hepar, Kali brom., K. phos., Lack., Lye, Mur. acid, Nit. acid, Phyto., Pic. acid, 
Bhus tox., Secale, Sil., Tarent., Vipera. 



ANTHRAX 

(Anthrax maligna; Splenic fever carbuncle; Malignant pustule, etc.) 

Definition. — A gangrenous inflammation of the skin beginning at the 
point of infection, followed by systemic disturbances due to inoculation of 
a virus containing the bacillus anthracis derived from animals suffering 
with splenic fever. 

The poison of splenic fever may be communicated to man by the respira- 
tory or digestive tract and prove rapidly fatal. It is only the more usual but 
fortunately rare infection of and through the skin which is considered here. 

Symptoms. — Within twenty-four hours after accidental inoculation, gener- 
ally on the more exposed parts of the hands or face, a single painless macule 



348 ANTHRAX 

appears, followed soon by the development of an angry, itching papule, which 
in turn is rapidly transformed into a vesicle or vesico-pustule partly filled with 
bloody serum. The redness has meanwhile spread, surrounding the centre with 
a deep scarlet areola, and underneath the skin and subcutaneous tissue have 
become infiltrated, resistant and outwardly rather sharply defined or merging 
into oedema of the adjacent tissues. The region involved may vary in extent 
from a dime to the palm of the hand. The central lesion soon ruptures and 
reveals a slightly depressed, oedematous, dark and often gangrenous patch, 
which in the course of another day may be surrounded by a circle of 'newly 
formed vesicles. The lymphatics and glands enlarge, sometimes suppurate ; the 
gangrenous patch may spread rapidly, general infection follow with rigors, 
high fever, occasionally becoming typhoidal in character. In severe cases death 
soon occurs from shock, blood poisoning or exhaustion. More often the local 
process is less rapid and the systemic disturbance less marked, amounting 
perhaps- to only slight chills, moderate fever, which do not confine the patient 
within doors. In the mildest cases or when controlled early by treatment con- 
stitutional symptoms may be absent, the local process is circumscribed and 
the gangrenous mass sloughs off in due time. Exceptionally in place of the 
usual lesion the disease may take the shape of a widespread, malignant oedema, 
spotted with gangrenous points and bullse rilled with sanious fluid. This man- 
ner of infection is almost invariably fatal. Between the mildest form and the 
most malignant may be all grades in the intensity and extent of the local 
process, accompanied with corresponding systemic manifestations, but in all 
cases there exists the possibility of malignancy. The duration varies in fatal 
cases from two to eight days, in favorable cases recovery is usually protracted. 

Etiology and Pathology. — The disease is due to infection through some 
slight abrasion or opening in the skin with the germs of splenic fever, and 
occurs almost exclusively among those whose occupations bring them in con- 
tact with live or more often the flesh of dead animals, such as cattle dealers, 
butchers, tanners, wool sorters, etc. Occasionally it may be conveyed by flies 
or in the dust from the hair or hides of animals, while it is claimed that the 
milk or butter of diseased animals or the imperfectly cooked flesh of recently 
slaughtered animals have produced it. The disease is more common in Con- 
tinental Europe, where splenic fever in cattle prevails, and is relatively rare 
in America, where that affection in animals is infrequent. 

The bacillvs anihracis, the largest of the pathogenic bacteria, is a rod- 
shaped germ 1-25,000 to 1-12,500 of an inch in diameter. It is found in great 
numbers throughout the affected tissue of the anthrax lesion, including the 
fluid of the pustule, and after a few days may be found in the excretions — 
urine,, sweat and faeces. In fatal cases the bacilli may be found post mortem 
in the capillaries, especially of the liver, kidneys and spleen. The presence 
and proliferation of this specific bacillus and generation of its toxine in the 
skin excites very acute and intense sero-fibrinous inflammation, with conse- 
quent thrombosis of the arteries and rapid tissue necrosis. 

Diagnosis. — Malignant pustule is characterized by very rapid development 



ANTHRAX ■> i ' J 

of papule, vesicle, pustule and gangrene situated on a deep, resistant, highly 
colored base surrounded by oedema, and on the second day by the pathognomonic 
sign, a depressed eschar encircled by vesicles. Carbuncle, furuncle, poisoned 
wounds and chancre can be excluded by their more indolent onset and course. 
The bacillus is readily found in the fluids of the anthrax lesion, and may be 
detected with the aid of the microscope, so that a suspected case need not long 
remain in doubt. This holds true of the rare form characterized by rapidly 
diffused oedema, which may resemble in some degree erysipelas, phlegmon and 
malignant oedema. 

Prognosis. — The chances of recovery from cutaneous anthrax depend 
largely on early and effective local and systemic treatment. Hitherto the 
mortality has been large; in the widespread cedematous variety the death-rate 
is still higher, and internal anthrax is nearly always fatal. 

Treatment. — Deep and thorough saturation of the affected tissues with 
antiseptics, or complete excision of the lesion under strict antiseptic precau- 
tions, to prevent infection of cut surfaces, followed by frequently renewed anti- 
septic dressings, are the two methods of local treatment indicated for this 
grave disease. Good results have followed, even in severe cases, from hjpo- 
dermic injections of pure tincture of iodine, one to three syringefuls being 
placed beneath the skin about the periphery and centre of the patch and the 
tincture freely applied to the surface. One of my own cases made a good 
recovery under treatment with iodine, locally and internally; another milder 
case responded to a one per cent, solution of permanganate of potash locally 
and crotalus internally. Carbolic acid injections in five per cent, solution or 
stronger have also been employed with success. The needle of the syringe may 
be inserted at the periphery of the patch with the point inclined to the centre, 
pushed in deeply and the injection made as the needle is withdrawn. Iodine 
or carbolic injections can be repeated at a half dozen or more points to reach 
all parts of the infiltration, and renewed every five or six hours until the spread 
of the disease is arrested, or indications of the toxic effects on the system of 
iodine or carbolic acid appear and force their suspension. Excision is gener- 
ally advised, and a choice of the two methods must depend in a measure on 
the location of the lesion and the facilities for observing the effects of treat- 
ment in each case. 

European observers have recently reported good results from the use of 
the serum prepared by Professor Sclavo of Siena. Italy; and when it is possible 
to procure this ingredient it should be tried, for apparently hopeless cases 
treated with the intravenous injection of this fluid have recovered. Usually 
it is introduced subcutaneously and is well borne in large doses, with Blight 
destruction of tissue and rapid convalescence. 

A nutritious diet or forced feeding, if necessary, is important, in view of 
the undermining and exhausting effects of the disease on the general system, 
and when the latter is involved alcohol in some form may be used freely both 
for its stimulant effect and its antidotal action on animal poisons. The indi- 
cated drug should be chosen on general as well as on local conditions prominent 



350 DISSECTION WOUNDS 

in each instance. Frequently the snake poisons or other preparations of 
animal origin will be found to be the nearest similium. See Anthracinum, 
Crotal., Kali phos., Secale, Tarent., Vipera. 



DISSECTION WOUNDS 

Accidental inoculation of an abrasion, cut or open follicle of the skin with 
virus from a dead body may give rise to the rapid production at the site of 
poisoning of vesico-papule, papulo-pustule. furuncle, tubercle, wart or hemor- 
rhagic bleb ; or there may be little or no local disturbance, with a rapid develop- 
ment of septicaemia or glandular enlargement. The nature of the disease which 
caused death and the length of time which has elapsed since that event, as 
well as the health of the person infected, will influence the effect produced. 
Aside^rom the particular infecting element of certain affections, such as 
anthrax, glanders, tuberculosis, which are described elsewhere, little is known 
regarding the nature of post-mortem poisons. When derived from disease 
they are most virulent in recently dead bodies, but it is quite probable that 
the decomposition of proteid substances known as ptomaines may be the source 
of cadaveric infection through the skin as well as other avenues of entrance 
to the human body. Generally when the effect of these poisons is entirely 
or chiefly limited to the skin the result is local and not serious, but when the 
cellular tissues or lymphatics are involved the condition is grave and may end 
fatally. The latter conditions fall within the province of the general surgeon 
or physician rather than the dermatologist. There remains one characteristic 
lesion which calls for brief mention. 

Post-mortem pustule. — This may be recognized as a result of inoculation 
of some slight abrasion, scratch or puncture of the skin, which is manifested 
soon by redness, heat and itching. During the second day a small pustule is 
formed attended with pain and tenderness, which is quite relieved when the 
pustule is opened, but these sometimes return again as the pustule refills. If 
allowed to go on, this process may be repeated a number of times, with a 
successive increase in the size of the ulcer base. Sometimes the lymphatics 
and glands are S3 r mpathetically affected and slight constitutional symptoms 
are noticed. 

The history of the case easily distinguishes it from the pustular or ulcera- 
tive lesions of other diseases. The treatment is purely antiseptic. The 
pustule may be opened and thoroughly washed out with hot borated water, 
dried and packed or dusted with boric acid powder, nosophen or aristol, covered 
with gauze or absorbent cotton and sealed up with a sufficiently large piece 
of rubber adhesive plaster. The dressing may be renewed twice daily until 
the lesion is healed. Apis or Crotalus may be indicated. 



RHINOSCLEROMA 851 



RHINOSCLEROMA 

Khinoseleroma has been frequently observed in Austria and Russia, but 
is very rare in this country. The disease consists of a rounded tumor that 
usually appears on or about the anterior nares. It is characterized by slow 
growth, extreme hardness, painlessness and invariable recurrence after 
excision. It does not ulcerate, and except for this recurrence is perfectly 
benign. The skin covering the growth may be normal or hyperaemic, but the 
hairs and glands are not discernible. The process may extend to the pharynv, 
larynx, lachrymal sac, lips, gums, trachea, jaws and soft palate. 

Etiology and Pathology. — This disease has been observed in both sexes 
•of various social conditions, and usually between the twentieth and fortieth 
years of life. The anatomical lea lures are a dense infiltration of the corium, 
•especially its papillary layer, with collections of small round cells. In 1882, 
A. von Frisch found in these cells a specific bacillus which was encapsulated 
in a colloid substance in series of twos and fours. Hence it is probable that 
the disease is a chronic inflammation due to the action of this bacillus or 
its products. 

Diagnosis. — The situation of the growth in the nose or upper lip, its slow, 
painless and progressive growth, ivory-like hardness without any tendency to 
soften or break down, may easily distinguish rhinoscleroma from sarcoma, 
■epithelioma or syphilitic infiltrations. "Where the skin covering the tumor is 
hyperaemic it may resemble keloid; rhinoscleroma is usually deeper situated 
than keloid, firmer, with a less irregular border, and is not likely to have a 
history of injury to the part. In a doubtful case a section of the growth can 
be removed and examined microscopically. The bacilli can be demonstrated 
best, according to Pollitzer, by twenty-four hours' staining with gentian-violet- 
aniline water decolorizing by Gram. These organisms are said to resemble 
•closely Fricdlanders pneumococcus. 

The prognosis is unfavorable as to cure ; the disease is likely to produce 
great discomfort from stenosis of the nose, and if located in the throat may 
cause death by suffocation. 

Treatment. — No method of treatment has proved satisfactory. If re- 
moved by the knife or curette the growth returns. When obstruction of the 
nostrils threatens, nasal bougies or sponge tents may be used to keep them 
open. After stenosis has occurred the growths can be bored through to give 
passage to air. Operative wounds of the tumors are said to heal kindly. Any 
indicated drug may be given internally — see Cal. phos. and Thuja. As the 
growths are reported to have undergone resolution after toxaemie fevers, if 
is possible a curative toxine may be discovered. 



352 ORIENTAL BOIL 



ORIENTAL BOIL 

(Delhi boil; Aleppo evil; Endemic boils; Furunculus Orientalis; Biskra or 
Biscara button.; Gafsa button; Natal sore, etc.) 

Definition. — A local disease, endemic in limited districts in tropical 
or semi-tropical countries, characterized by the appearance successively 
in the course of months, usually on the face or other exposed parts, of a 
papule, tubercle, crust over a hidden ulcer and a final indelible scar due 
to the presence in the tissues involved of a micro-organism. 

Symptoms. — Sometimes only one lesion appears, bnt commonly there 
are several, and rarely many; they are situated most frequently on the elbow, 
forearm, hands, ankle, leg, face and thigh, never on the scalp and rarely on 
the trunk. The lesion begins as a small red papule, slowly enlarges to the 
size of a pea or larger, covered by the smooth, shining red, slightly elevated 
and unbroken skin. In this condition it may remain for weeks or months 
before the surface becomes studded with numerous whitish points, and a central 
opening occurs in the tubercle, giving exit to a serous fluid which dries into an 
adherent crust. The crust gradually increases by segments until it covers the 
whole nodule, which may be surrounded by a red zone on which papules may 
appear. Underneath this crust disintegration of the nodule goes on for weeks, 
gradually forming a round- superficial or deep ulcer, which if uncovered shows 
an irregular, sharply defined border, uneven floor, perhaps ulcerating at some 
points and covered with fungating granulations at others. Sometimes these 
ulcers reach the size of a silver dollar, or two or more may coalesce into irregu- 
lar patches and continue to secrete an offensive sero-purulent fluid which forms 
bulky adherent crusts. Finally, reparative granulations spring up on the 
floor of the ulcer, gradually heal at the periphery, and the resulting scar may 
radiate in ridges from the centre. 

The whole duration of the lesion varies from six to twelve months, rarely 
longer. Generally there is an absence of painful sensations, except in cool 
weather, when there may be nocturnal neuralgia and pruritus sufficient to 
disturb sleep. 

Etiology and Pathology. — In regions of certain countries where the 
disease is endemic neither sex, age, race nor nationality gives immunity from 
it, and, though it rarely occurs in young infants, few native children reach 
maturity without having an attack. Climate and season appear to be limiting 
factors; its geographical boundaries being pretty sharply defined within tropical 
climates, and within these, its foci of endemic prevalence may be isolated by 
zones of complete immunity. The influence of season is shown by the predomi- 
nance of new cases from the beginning of September to the first of January, an 
absence of new cases after the month of April, and, through recoveries taking 
place in the meantime, the least prevalence of the disease is observed in the 
early autumn. Most authorities agree that infection takes place from without 



PHAGEDENA TROPICA 353 

into the skin through some slight or considerable break in its surface from irri- 
tants,, blisters, vaccination, the eruption of other cutaneous affections, slight 
traumatisms and the bites of insects, and the weight of evidence tends to show 
that the development of the local distinctive inflammatory process peculiar 
to this disease is due to the invasion of a micrococcus, which Wright named 
heleosoma tropicum. 

Diagnosis. — The endemic nature, location on exposed parts, slow evolution 
and absence of marked local or general disturbances will, with a little time for 
observation, easily differentiate Oriental boil in its early stages from ordinary 
furuncle and carbuncle, or from ecthymatous, rupial or ulcerative lesions of 
syphilis, lupus, yaws or other affections. 

Prognosis. — Recovery is said to nearly always follow uncomplicated at- 
tacks, but there is liability to the formation of disfiguring scars when the 
disease is neglected, especially if it is located on the face. One attack affords 
no absolute protection against another. 

Treatment. — Probably the same methods of treatment as detailed for 
furuncles or carbuncles would abort or greatly modify the duration of Oriental 
boil. Altounyou has reported good results from painting with tincture of 
iodine. Injections of iodine or ten per cent, solution of carbolic acid, as sug- 
gested by Crocker, into and around the affected area before it has broken 
down, might prove beneficial. Preventive measures consist in cleanliness, at- 
tention to sanitary and hygienic principles of living and avoidance of all 
sources of infection. 

PHAGEDENA TROPICA 

(Tropical phagedenic ulcer; Aden ulcer; Malabar ulcer, etc.) 

Definition. — An ulcer of tropical climates beginning at any point of 
injury to the skin and rapidly extending, with more or less gangrenous 
destruction of the parts. 

Symptoms. — This disease occurs in tropical regions the world over and 
in a few temperate climates, such as that of Egypt and Algiers, but is espe- 
cially frequent and severe in the islands and main shores about the Eed Sea 
and Cochin China. 

The disease is chiefly seen in persons suffering from some loss of vigor 
from fatigue, anaemia, malaria, and nearly always occurs on the feet or ankles, 
occasionally on the hands and forearms and rarely on other portions of the 
body. Commonly at the site of some lesion of the skin from a scratch, puncture, 
bite of an insect or other breach of the surface, there soon appears a vesicle 
or bulla, rapidly changing to a pustule around which the parts become red and 
cedematous. The infiltration extends laterally and inwardly, followed closely 
in severe cases by the formation of a grayish or darker slough, under which 
the tissue rapidly disintegrates down to the muscular layers ; these yield more 
slowly to the destructive process, but eventually disappear, together with the 



354 ELEPHANTIASIS 

longer resisting nerves and blood-vessels, until finally the bone may be attacked 
and the outer plate destroyed. 

In milder cases only a superficial ulcer is formed by the separation of the 
slough, discharging for a variable time an abundant sanious pus, and then 
changing into an atonic ulcer which, under favorable conditions, after weeks 
or months, gradually heals by cicatrization. - 

Etiology and Pathology. — The disease occurs chiefly among the native 
colored people who live in the hot countries where it prevails. White residents 
and visitors are much less subject to it and then in a less severe form. The 
undermining influences of privation, exposure, debility, cachexia and over- 
work appear to create a predisposition to the disease, especially in its more 
severe forms. The pathogenetic cause is believed by Boinet to be a microbe 
which lives in the water and mud of the infected regions. From cultivation 
of this micro-organism he has successfully inoculated animals, and has seen 
clinical signs that the pus is inoculable. 

The diagnosis may be made without difficulty from the occurrence of the 
disease in hot or warm climates, its local origin at some point of injury to the 
skin and from other features of its clinical history. 

Treatment. — Since the disease is infective all patients should be iso- 
lated. Local treatment should be antiparasitic, adapted to the intensity of the 
morbid process. In the severe cases application of pure carbolic acid was 
found by Parke to arrest the destruction of tissue and bring about healthy 
granulations after separation of the slough. Subsequent dressings with unirri- 
tating antiseptics, such as three per cent, creolin in glycerine, nosophen, aristol, 
or iodoform, are probably sufficient. In mild cases one of the latter dressings 
only may be needed. Physiological and hygienic methods of treatment should 
be directed to the relief of the general condition of anaemia, malaria, etc. 
Here also with the local indications will lie the choice of a drug remedy. 
Among them consult Kali biclirom. and Lycopodium. 



ELEPHANTIASIS 

(Elephantiasis arabum; Pachydermia; Elephantiasis Indica; Bucnemia trop- 
ica; Morbus elphus; Elephant leg; Barbadoes leg; Cochin China leg, etc.) 

Definition. — A chronic disease of the skin and subcutaneous tissues of 
certain regions of the body, arising from the local obstruction to the flow of 
blood or lymph, and resulting often in enormous enlargement of the affected 
part. 

The term elephantiasis is now restricted to conditions alike in their patho- 
logical development, and not to varied forms of growth, such as the large 
lipomata, fibromata, enlargements in leprosy (elephantiasis gracorum). for- 
merly included under this generic name. 

Symptoms. — The disease occurs endemically in tropical or sub-tropical 
climates, and is there chiefly clue to blocking of the lymph' vessels by the 




Fig. 101— ELEPHANTIASIS 



EARLY STACK OF SPORADIC FORM 



Patient is a married woman of fifty-five, who has been well until nine months 
ago. Then the right leg was suddenly 'attacked with inflammation, attended with 
deep sticking pains and a sense of heaviness. The acute symptoms subsided in two 
weeks, leaving the leg enlarged and darker in color. Subsequently lighter attacks 
have occurred every few weeks, each perceptibly adding to the size of the leg. From 
the knee to the foot the skin is firm, non-elastic, cool to touch, purplish, does not pit 
on pressure and is beginning to be uneven, lobulated or tidgcd. Bruised sensations 
are felt on walking or standing, with an increased sense of general weariness and 
depression. Symptoms relieved and leg nearly reduced to normal size by frequent 
rest in recumbent position and the administration o! hydrocotyle, third decimal, and 
later cakaren fluoratn, sixth decimal. 



ELEPHANTIASIS 

filaria sanguinis hominisj it occurs sporadically in temperate climates from 
obstructions of the lymph or blood-vessels due to growths or inflammatory 
indurations. These two forms, differing thus in initial origin, are practically 
identical in their further pathology and ultimate effects on the parts involved, 
which vary from moderate thickening of the whole or parts of the skin and 
subcutaneous tissue up to gigantic enlargements of the same, with, of course, 
corresponding variations in aspect. Elephantiasis usually attacks the leg or 
foot, rarely on both sides; less often the thigh or buttock, and occasionally 
other parts, such as the scrotum and penis in men, the labia and clitoris in 
women, the upper extremities, parts of the face, the ears, and, very exceptionally, 
other regions of the body. It may begin in either endemic or sporadic cases 
as a genuine erysipelas, with the symptoms of that affection, or it may simulate 
the latter in appearance and sensation from infiltration of the subcutaneous 
tissue, swelling, vivid redness, and tension of the skin. In places where this 
disease is endemic there is often antecedent febrile disturbance (elephantoid 
fever), sometimes intense, alternating perhaps with stages of perspiration, 
severe lumbar or joint pains, nausea, vomiting and chilliness. These symptoms 
may, however, appear without the fever. If the lymphatics are much involved 
there may be vesicles or bullae formed, from which a colorless or milky fluid 
is discharged on the surface, and. when the scrotum is the part affected, acute 
hydrocele may develop, with intense pain in the groin, along the spermatic 
cords and in the testicles. After a time the acute symptoms subside, leaving 
the part somewhat enlarged. Subsequent attacks varying in intensity and 
frequency add, with each recurrence, to the bulk of the enlargement until a 
limb may be three or four times its natural size, or the scrotum may sometimes 
continue to progressively enlarge, in extreme cases, until it engulfs the penis, 
weighs a hundred pounds and reaches below the knees. Like gigantic enlarge- 
ments may occur, only less often, in the external genitals of women. Other 
parts of the body seldom undergo such gigantic growth as may take place in 
the leg or genitals. In the intervals between the exacerbations of the disease- 
the patient may be quite free from suffering beyond the inconvenience propor- 
tionate to the abnormal bulk of the affected part. If there is much or pro- 
longed drain of lymph from rupture of the integument considerable weakness 
may result. 

When well-developed elephantiasis of the leg exists, it is found on inspec- 
tion to be greatly swollen and cadematous, but hard and resistant to pressure, 
showing subcutaneous involvement as well as marked hypertrophy of the skin 
itself. This is often most marked along the sides of the natural lines of the 
skin, transforming them into deep sulci, especially exaggerated at the flexure 
of a joint. Prominent papilla? may also elevate the surface more or less here 
and there in the form of warty plaques covered with thick, hard or softened 
epidermis, which together with the varicosed lymphatics, or deep protrusions 
from them, give to the reddish-brown or deeper stained skin an uneven, irregular 
surface. Less often the surface may be quite or comparatively smooth unless 
complicated with eczema, which is not uncommon, and attended with severe 



I 



350 ELEPHANTIASIS 

. itching, adding greatly to the discomfort of the patient. Varicose ulcers may 
further complicate the surface conditions, neighboring glands are usually 
affected sympathetically, and occasionally keloidal growths appear on the sur- 
face. In the linear depressions of the skin before mentioned the imprisoned 
sebum and sweat decompose, and with the macerated epithelium cover the 
opposing surfaces with a slimy, offensive fluid. In advanced cases sometimes 
scattered scars may be found mingled with other lesions, marking the site of 
former ulcers or other losses of tissues. Earely the bones of the limb are in- 
volved in the hypertrophic process (similar to acromegaly), and enlarged 
in all dimensions, contributing to the unwieldiness of the member. In the 
endemic form both limbs are often affected, but in most cases occurring in 
temperate climates one limb only is involved. Elephantiasis telangiectodes is 
a name given by Virchow to a congenital vascular naevus which, on subsequent 
development, gives the limb a lobulated feel and enlargement, but firm pressure 
on the part temporarily empties the vessels of their contents. 

Etiology and Pathology. — Climatic conditions found in warm countries 
in connection with bad living, malaria, especially as affecting the dark races, 
appear to predispose to elephantiasis, and removal from regions where it is en- 
demic is said to arrest the disease, which, however, recurs if the patient returns 
to the former district. Yet it occurs sporadically nearly all over the globe 
except at the Poles, and Manson argues that its geographical distribution 
is limited to that of the mosquito. Claims have been made that some cases a/e 
congenital in origin; the affection begins, however, chiefly in adult life, and 
is three times more common in men than in women, probably from equal 
differences in exposure of the two sexes. The essential or pathological causes 
have been referred to incidentally in discussing the endemic and sporadic types 
of the disease. According to Unna, the primary pathology consists in local 
venous stasis and obstruction to the escape of blood, both in elephantiasis 
filariosa and the sporadic form, which may follow on the tissue changes left 
by erysipelas (fibrinous thrombi in the capillaries and veins) and other affec- 
tions. He does not ascribe the local changes to the presence of filaria in suffi- 
cient number to block up the lymphatics or glands, both of which are perme- 
able to the embryos, but to the venous stasis from their first invasion, and the 
fibrinous inflammation (with erysipelas-like symptoms) to the penetration of 
the filaria into the skin. The periodic exacerbations of the disease correspond 
to the recurring emigration or swarming of the organisms in the circulation, 
which in the case of filariosis is cyclic in nature and may be complete inside the 
human body or occur partially without. According to Manson, the filaria are 
taken into the body in drinking water, find their way into the lymphatic chan- 
nels, there discharge their ova, which are swept along in the lymph current to 
the glands. Here they hatch out and the embryos pass on through the lym- 
phatic vessels into the circulation, where they are especially active in the 
capillaries at night. Mosquitoes abstract them from the blood, retain them 
during further development and then transfer them to water, to reach man 
again when the contaminated water is drunk. Besides the causal relation 



ELEPHANTIASIS 86f 

of erysipelas to the development of sporadic elephantiasis, pathological effects 
on the circulatory apparatus in the skin from phlebitis, phlegmasia alba dolensj 
obstinate or repeated attacks of eczema, psoriasis, or other inflammations may 
be the exciting factors; or mechanical obstructions from tumors, gummata, too 
closely applied bandages or appliances may induce the primary venous or lym- 
phatic stasis. In fact, the mechanical is an element in the operation of all 
causes and accounts for the occurrence of the disease more often in parts where 
the circulation is most easily impeded, as in the lower extremities and genitals. 
A predominance of hypertrophy of the tissues with a minimum of lymph stasis 
or dilatation occurs usually in sporadic elephantiasis ; while the filarial or en- 
demic form may present a chain of symptoms scarcely distinguishable from 
the former, the lymphorrhceic type may predominate, as in the lymph scrotum', 
often to the extent of an exhausting lymphorrhagia. 

Diagnosis. — This is easy from the objective features of elephantiasis (usu- 
ally limited to one limb) of pronounced enlargement, firm oedema, hardness of 
the surface, with perhaps papillary elevations, varicose lymphatics, together 
with a history of occurrence from repeated attacks of erysipelas, persistent or 
recurrent inflammations of the skin of the affected region, mechanical obstruc- 
tions to the circulation acting from without or from within, and in tropical 
countries from the history of attacks of "elephantoid fever." In syphilitic 
cases some evidences of the previous local lesions can usually be found in 
the shape of thin, ovoid, circular or figurate scars unattached to the part 
beneath. Deep brown or blackish stains may be left from varicosed vessels, 
varicose ulcers or from eczematous inflammation. 

Prognosis. — Life is not so much imperiled by the disease as existence is 
burdened by the enlargement of the extremity, genitals or other parts. Eemoval 
from an endemic district is said to quickly benefit cases of elephantiasis fila- 
riosa. In sporadic cases relief will often depend on the removal or modification' 
of the cause in the early stages, and on the utility of surgical measures in 
the later stages. 

Treatment.— This must be directed, when practicable, to the causal condi- 
tion or agency which led up to the elephantiasis, and as the causes of the 
disease may be one or more of many different influences, it follows that the 
causal treatment must be adapted to each individual case. It may, therefore, 
look to the betterment of general and special hygiene, such as removal" from 
an endemic district, better sanitation, diet, and other improvements in the 
mode of life of the individual. The local conditions of obstruction call 
for such mechanical methods as even support with a rubber bandage by dav 
and a wool or cotton roller at night. Good residts have been attained by 
long use of this method of compression in connection with internal treatment; 
By these means the veins and lymphatics regain tone, some absorption occurs 
with consequent lessening of the oedema and size. Surface affections, such 
as eczema, ulcers, etc., should receive attention suited to their local needs, 
but the routine use of inunctions or the application of so-called absorbents; 
except for syphilitic gumma, are not recommended. In advanced elephantiasie 



358 TUBERCULOSIS CUTIS 

enlargement, especial])' of the genitals, the improved methods of surgery offer 
the best results. The chief objection to surgical treatment is the frequent 
occurrence of lymphangitis. Nerve-stretching has been reported as success- 
ful in a number of cases. Galvanism and massage may be useful in some 
inoperable cases of the disease affecting the face or other parts of the surface. 
Eest and elevation when the limbs are involved are probably serviceable in all 
cases, and in the acute exacerbations of the disease are essential to the best suc- 
cess of efforts to modify the attacks by internal treatment. The latter may 
be adapted to the nature of the acute process, whether it be an erysipelas or 
other kind of inflammation. The choice of an internal remedy in the intervals 
between acute aggravations may rest on the indications present in a given case, 
but the existence of any specific or constitutional cause should not be for- 
gotten in this connection, and preference given to drugs which act on the 
fibro-muscular structures of the skin. The author has seen good results 
follow such medication in the early stages of sporadic elephantiasis without 
the aid of local treatment. Among other drugs see Cal. fluorica, Hydrocot. 
and Silicea. 

TUBERCULOSIS CUTIS 

General Considerations 

Among bacillogenous diseases of the skin there are none of such interest 
and clinical importance as the varieties of primary and secondary tuberculosis, 
especially in their possible etiological relation to tuberculosis of the internal 
organs, the mortality from which dwarfs in extent that of any modern disease. 
The scientific investigations of Koch and others have demonstrated the 
presence of a specific organism — the tubercle bacillus, in the lesions of both 
internal and cutaneous forms of the disease, and that inoculations with cultures 
of these bacilli will produce the same disease in susceptible animals. The 
vulnerability and reaction of the tissues to this organism vary widely, and 
account on the one hand for individual immunity from the disease, and on 
the other for the varieties of its clinical manifestations in those infected. The 
tubercle bacillus is only feebly infectious, and the wide distribution of tuber- 
culosis is probably due to its general and constant prevalence. Low vitality 
of tissues, either hereditary or acquired, particularly the scrofulous diathesis, 
may create a predisposition to tuberculosis, but there is every reason to believe 
that the actual disease is always acquired, and that no child is born tuberculous. 
Cutaneous forms of the disease are much more common than is generally sup- 
posed, and some chronic ulcers, warty growths as well as the forms of lupus 
vulgaris, are now known to be varieties of tuberculosis. They frequently 
originate in early life owing to the less resistance of the skin and the more 
indiscriminate contact of the hands with persons and things during child- 
hood. In crowded habitations, where, from lack of means or inclination, clean- 
liness is unknown, accidental abrasions or the presence of simple inflammatory 



TUBERCULOSIS CUTIS ORIFICIALIS 859 

affections of the skin or mucous membrane afford not infrequent avenues for 
infection by contact, if general or local tuberculosis is present in the circle of 
neighborly people. Although tuberculosis of the integumenl is only moderateh 
contagious owing to the few bacilli commonlj present in the lesions, secondary 
infection (chiefly pulmonary) has been observed by Leloir, Besnier, llaslund 
and others in Europe in sufficient number to show the possible danger from 
the cutaneous disease. Haslund of Copenhagen found in bis clinic that 
lupus patients had pulmonary, tuberculosis in the large proportion of sixty 
per cent. In America few instances of undoubted secondary infection have 
been recorded. My own observation of many cases of both cutaneous and 
pulmonary tuberculosis leads to the conclusion that cases of the former seen 
in this country seldom result in secondary infection of internal organs, while, 
on the other hand, certain rare cutaneous forms are frequently secondary to 
pulmonary phthisis. Indeed, the latter disease from its great prevalence is 
probably the chief source of infection directly or indirectly for all other 
forms of tuberculosis. 

There still exists some confusion as to the relation of scrofula and tuber- 
culosis. The modern conception of scrofula is that of a special diathesis or 
existing proclivity of the tissues to disease, and not a definite form of morbific 
change. The form is determined by the nature of the exciting cause. This 
delicacy of the tissues of the strumous renders them abnormally susceptible to 
injurious influences of many kinds, but particularly to the action of pathogenic 
micro-organisms, and especially to the tubercle bacillus. The term scrofulo- 
derma is, therefore, still employed to designate a type of cutaneous tuber- 
culosis supposed to be largely dominated by the strumous diathesis and 
affecting chiefly the glands and subcutaneous tissues. Tuberculosis of the 
skin may be conveniently studied in four divisions: A. Tuberculosis cutis 
orificialis. B. Tuberculosis verrucosa. C. Lupus vulgaris. D. Scrofulo- 
derma. Lichen scrofulosis and erythema induratim are probably of a tuber- 
cular nature, and will be considered separately. 



A. TUBERCULOSIS CUTIS ORIFICIALIS 

{Miliary tuberculosis; Tubercular ulcers; Ulcer of the phthisical, etc.) 

This division includes forms which were once supposed to be the only 
manifestations of integumentary tuberculosis. Primary forms are exceed- 
ingly rare, and are- probably then due to direct inoculation from another 
person suffering with tuberculosis. Nearly always it is secondary to pulmo- 
nary or intestinal tubercle, and the lesions are almost invariably situated at 
the junction of the mucous membrane and the skin at the mouth, nose. anus. 
vagina and penis. In comparison with pulmonary tuberculosis orificial tu- 
berculosis is exceedingly rare. Chiari, who was one of the earliest to recog- 
nize the nature of these ulcers, examined about four thousand tuberculous 



3G0 TUBERCULOSIS CUTIS ORIFICIALIS 

bodies, and found only five with ulcers at the outlets of the body, and these 
all on the lower lip. In nearly a thousand eases of phthisis seen by myself 
only one has presented an undoubted tubercular ulcer, situated on the 
lower lip. One primary case has come under my observation in a young 
girl, who neither before nor since the ulcer healed has shown any other 
sign of tuberculosis. In this case the ulcer was situated at the centre of the 
lower lip, where a slight fissure had previously existed for a few weeks. How 
inoculation occurred could not be ascertained. Where tuberculous ulcers 
have been found at the orifice of the anus, vagina or glans penis they have 
been found secondary to intestinal or genito-urinary tuberculosis. 

The lesion is commonly single, but may be multiple and later run together 
to form irregular or serpiginous ulcers. The single ulcer often presents a 
quite characteristic appearance. It is shallow with a gnawed-out look, due to 
degeneration of miliary tubercles at the edges, leaving jagged indentations, 
and sometimes over the floor yellowish elevations consisting of tubercle 
nodules. Occasionally the surface is crusted over, more often it is covered 
with a sero-purulcnt secretion. The single ulcers rarely attain a large size, 
but show no tendency to heal, and if neglected may by slow infection of con- 
tiguous parts finally involve quite a large area of skin. Unlike other forms 
of cutaneous tuberculosis they are often painful and sensitive, probably owing 
to the friction, tension and irritating secretions to which they are more or 
less exposed at the orifices of the body. Sometimes they seem to give but 
slight annoyance, and occurring more often in the late stage of tuberculosis 
are probably little heeded in the presence of the extreme symptoms of the 
primary disease. The mucous surfaces of the mouth, tongue and throat are 
frequently affected when the ulcers occur at the mouth and exhibit similar 
characteristic ulceration as upon the skin, while the pathognomonic miliary 
lesions in the vicinity of the ulcers are more commonly seen on the mucousi 
membrane than about the like lesion on the skin. In fact this form of ulcer 
on the tongue was recognized long before the nature of the cutaneous lesion. 

The etiology of orificial tuberculosis is clear. Some slight abrasion or 
simple inflammatory lesion at or near the margin of an outlet of the body 
in those suffering from internal tuberculosis, and over which pass sputum or 
other secretions or discharges containing tubercle bacilli, afford the con- 
ditions favorable to auto-inoculation. Often in these cases tuberculous ulcers 
of the mucous membranes also exist. They may occur when the signs of 
internal tuberculosis are slight or absent, and it is quite probable, from the 
evidence of a few cases reported, that injuries of any part of the surface may 
be accidentally inoculated and develop primary or secondary tuberculosis of 
the skin according to the source of infection. Morris mentions such ulcers as 
beginning in a patch of eczema. These primary forms may resemble other 
varieties of cutaneous tuberculosis rather than the orificial, or they may pre- 
sent intermediate clinical forms. It is claimed that the habit of sucking the 
wound in the Jewish rite of circumcision has, when the operator was tubercu- 
lous, sometimes resulted in inoculation of the disease. 




Fig. 102.— TUBERCULOSIS ORIFICIALIS ET VERRUCOSA 



Patient is an elderly woman who has been subject to phthisis for many years. 
About three years ago a small ulcer developed on the lower lip, near the left com- 
missure, and has progressively spread around the colored border of the lip onto the 
right side. The ulcer is triangular, with soft edges and base, the latter covered with 
a purulent secretion, except near the lowest angle, where a blackish crust adheres; 
miliary tubercles are present in the mucous membrane of the mouth. Three warty 
growths have appeared on the skin of the face, the first and largest about two years 
aj;o. It presents the characteristics of a tuberculous wart. Scarlike formations on 
other parts of chin are credited to burns. The ulcer healed and the warty forma- 
ti ms disappeared under thorough daily cleansing, followed by painting the lesions 
with a one per cent, solution of corrosive sublimate. 




Fig. 103.— LUPUS VULGARIS 



NON-ULCERATIVE VARIETY 

Patient, an American woman of thirty-four years. No cancerous or tubercular 
family history. Twenty-four years ago the disease started as a small red spot, and 
has slowly increased until the entire side of the jaw as well as the external ear is 
involved. There are no symptoms except sensations of tension, slight scaling and 
the usual deep red appearance. Sixty exposures to the Finsen rays seemed to give 
some relief, but later treatments with the high frequency currents (Oudin resonator) 
relieved the tension, made the affected parts more mobile, and hastened the appear- 
ance of scar tissue. 



TUBERCULOSIS VERRUCOSA 861 

Pathologically, typical cases of tuberculosis cutis orificialis are identical 
with miliary tuberculosis of the lungs and otber parts. 

The diagnosis is readily made when undoubted pulmonary or other 
internal forms of the disease exist, and especially when associated with mani- 
festations of the disease on the mucous membranes. Even without these cor- 
roborating conditions the history and objective features of the lesions above 
described will generally distinguish them from the ulcers of other diseases, 
while microscopic examinations of cultures from scrapings from the surface 
of an ulcer may reveal the presence of the tubercle bacilli. Failure to find 
the pathogenic organism, however, is not proof that a tubercular disease does 
not exist. The prognosis as regards healing of the ulcer is reasonably good. 
Two of the three cases of my own healed kindly under treatment and have 
not returned, though one has had chronic phthisis for years. 



B. TUBERCULOSIS VERRUCOSA 

{Verruca necrogenica; Tuberculosis verrucosa cutis; Anatomical tubercle; 

Post-mortem warts.) 

This is a rare local form of tuberculosis of the skin due to direct inoculation 
of some break or lesion of the surface with tubercle bacilli. It occurs chiefly 
on the hands or fingers of persons who are in the habit of handling dead tissue 
containing living bacilli, and has long been known as anatomical wart. It may 
develop on the hands of physicians engaged in dissections, post-mortem ex- 
aminations and from examinations or operations on tuberculous subjects; and 
more often probably on the hands of helpers in mortuary rooms, butchers, 
etc., who are less careful in the protection of slight wounds of the skin. It 
may also result from auto-infection in the tuberculous, as in a case of my 
own, and it has occurred in those intimately related to and caring for the 
phthisical over long periods of time. Unna looks upon lupus verrucosus, 
which sometimes occurs upon the hands, as clinically identical with this type 
of the disease, and McCall Anderson under the same name or scrofuloderma 
verrucosum long before described a similar affection occurring on the hands, 
elbows and knees of children. Bowen states he has observed cases of the disease 
on the hands of men in charge of cattle on the transatlantic steamships. 

The lesion of tuberculosis verrucosa develops very gradually as a rule. 
It usually begins as a flat papule, which after a time becomes pustular; the 
latter dries into a crust and is eventually shed, leaving exposed a surface made 
uneven by enlarged papilla?. Pustules may continue to appear at the border, 
while the papillae slowly become larger in the centre, until a prominent warty 
growth is formed covered with crusts and corneous epithelia. When a 
patch is increasing in size it is often surrounded by a rather broad band of 
erythematous skin, and during the periods of aggravation especially, pustules 
may form at scattered points over the surface, or pus can be pressed from 




3(52 TUBERCULOSIS VERRUCOSA 

between the papillary excrescences. There is seldom any tendency to ulcer- 
ation as in orificial tuberculosis, probably due to the differences of structure 
of the skin in the different locations affected. Nearly all cases show a pro- 
nounced tendency to papillary overgrowth, but the size and clinical appear- 
ance of the plaques may vary widely. The lesion may remain single, small 
and stationary, or beginning singly it may gradually enlarge up to three 
or more inches in diameter; or, again, new foci may form, remain isolated 
or contribute in the formation of a more or less irregular patch. Earely there 
may be little or no apparent papillary hypertrophy, and occasionally all signs 
of inflammation may be absent. 

The duration of verrucose tuberculosis is variable. Occasionally spon- 
taneous evolution takes place, with the resulting production of a cicatrix. 
This may occur more often than is supposed, because it is quite likely the 
nature of these warty growths is sometimes overlooked when they remain 
small, stationary and give little or no annoyance to the patient. On the other 
hand, if not interfered with, they may slowly enlarge for years. Hutchinson 
has mentioned a case which increased in size over a period of forty years. 

The predisposing influence of certain occupations above named and direct 
inoculation of some wound of the surface with matter containing tubercle 
bacilli make up the etiology of this form of direct cutaneous tuberculosis. 
No constitutional predisposition appears as a factor in these cases, for those 
attacked have been found usually in good bodily condition. The bacillus of 
tuberculosis has been found in the lesions more abundantly than in some other 
cutaneous forms of the disease, and inoculations have produced true tuber- 
culosis in animals. 

The reaction of the dermal tissues to the presence of the bacilli leading 
up to epithelial and papillary overgrowth is the most uniform pathological 
characteristic. Earely is the disease followed by systemic infection, though 
a few recorded cases of secondary involvement of the lymphatic glands and 
deeper vital parts indicate the possibilities in this direction. 

On the whole the prognosis may be said to be favorable in most instances 
for complete recovery. 

The diagnosis would only enter into a comparison with simple warty 
growths. The occupation of the subject, mode of occurrence, signs of inflam- 
mation, pustular lesions and other characteristics named will usually suffice 
to distinguish the anatomical wart from all others. Discovery of the tubercle 
bacillus by microscopic examination is pathognomonic, but failure to find 
the micro-organism is common and of slight negative value. 



LUPUS VULGARIS 



C. LUPUS VULGARIS 

Definition. — A tuberculosis of the true skin and mucous membranes, 
characterized by neoplastic formations, with the appearance on the surface 
of papules, nodules and patches, which may undergo various changes and 
finally result in destruction of the tissues involved by degeneration or 
atrophy, leaving scars. 

Tins is by far the most important, if not the most common, of all forms 
of cutaneous tuberculosis, and for its many clinical forms a great number of 
different names have appeared, from time to time, before its true pathology 
was understood. These qualifying terms for minor variations are no longer 
useful, but on the other hand confusing, and, therefore, will be mentioned 
only parenthetically in the text as the different phases of the disease are 
described. 

Symptoms. — The most typical lesion of lupus vulgaris is a soft, jelly- 
like pin-head to pea-sized nodule or " lupoma " of a dull red to a violet-red 
color and situated in the corium. It may be scarcely perceptible to touch, with- 
out elevation above the surface, but the color does not quite disappear on 
pressure, Lupus maculosus, Lupus planus. Usually this is only an early stage 
of the disease, but it may remain the type throughout its course. More often 
two or more lesions sooner or later develop simultaneously, successively or with- 
out order, producing one or more variously sized elevations of the surface, 
Lupus elevatus, L. nodosus, L. tuberculatus, tumidus. 

The lupus eruption generally pursues a very chronic course, sometimes 
apparently undergoing little change for ten to twenty years or even longer. 
It rarely ulcerates, but sooner or later an atrophic involution begins by a 
process of resorption and fibroid degeneration, Lupus non-exedens, L. non- 
ulcerosus. In these cases the lupus elevation gradually flattens and disap- 
pears, leaving the epidermic covering wrinkled and scaly, Lupus exfoliativus, 
L. psoriasiforme. When involution is complete a depressed cicatrix occupies 
the site of the former lupus lesion. Sometimes fibrosis is excessive and a 
sclerotic mass replaces the former lesion (Lupus sclerosus, L. fibrosus), but 
the keloid-like growth thus formed may still remain tuberculous. 

Lupus serpiginosus is a name given to an intractable form of the disease, 
in which the lesions continue to appear at the periphery, as others in the centre 
are undergoing absorption. This variety may extend over a wide portion of 
the face or an extremity and produce great disfigurement. 

In many cases the reaction changes in the tissues around the lupus in- 
filtrate account largely for the clinical features of the disease. Thus there 
may be thickening, oedema, hypertrophy, hyperplasia, lymphangitis, which 
suggested to the older writers such qualifying terms as Lupus hypertrophicus, 
L. elephantiaticus, L. papulosus, L. cedematosus. etc. "With or without the 
presence of these inflammatory conditions of the tissues of the affected part, 
the lupus growth having reached the acme of evolution may undergo a fatty 



364 LUPUS VULGARIS 

or cheesy degeneration, resulting in softening, giving way of the surface and 
the formation of a so-called ulcer, Lupus exulcerus. The open sore thus 
formed is probably at once infected with the micro-organisms of suppuration, 
hence the crusts which always form while the destructive process remains 
superficial are composed of the dried products of degenerating tubercle and a 
sero-purulent secretion, Lupus crustosus. The objective appearance of these 
crusts will vary with the activity of the septic process to which they are directly 
due. Indeed repeated microscopic examinations of the secretion from these 
open lesions may fail to discover any tubercle bacilli, but will show the 
presence of numerous pus cocci. When a crust is removed, however, the 
characteristics of the lupus sore will be found ; it is roundish in outline, with 
a well-defined, thin-edged, shallow and reddish margin, a grayish or dull 
reddish, granulating and sometimes hemorrhagic floor, and usually without 
parfTor sensitiveness to pressure. Another and almost pathognomonic sign of 
the lupus ulcer (and characteristic of nearly all tuberculous tissue) is the 
absence of induration or hardness, which permits even a blunt pointed instru- 
ment to readily pass through its surface before cicatrization or other fibrosis 
has occurred. The process of involution by resorption first mentioned, fibrous 
metamorphosis, and the later one of destructive degeneration by softening, 
may go on side by side in the same subject. New lupus tubercles may also 
appear at some points undergoing retrograde change, more often fresh nodules 
appear at the periphery of a patch, sometimes separated from the margin of 
the ulcer by islets of sound skin. Further advances of the disease and sub- 
sequent destructive process may be superficial, lupus superficialis. Or it may 
be deep, and following the gland structures, blood-vessels and lymph channels, 
attack and destroy fibrous, muscular, cartilaginous and rarely bone tissues in 
its course. Both superficial and deep advances may go on at the same time, 
lupus vorax. The process may be not only extensive in the region affected, 
but may be rapid in its course, Lupus phagedenicus. 

The acutely destructive forms of lupus are very rare and probably due 
to some secondary infection or to a peculiar idiosyncrasy of the individual 
to the liquefying process of the retrograde stage of the disease. But in another 
distinct type of lupus vulgaris, termed by TJnna lupus diffusus radians, there 
is a much greater tendency to extension, probably from the early and continued 
involvement of the blood and lymph structures of the skin. In this not 
infrequent form the lupiis nodule is not so apparent or its presence in the 
skin is masked by a persistent erythema, which if pressed away with a glass 
slide brings into sight a translucent spot without regular or definite margin. 
In rare cases the tuberculous deposit may be insignificant in comparison 
with the extensive, superficial erythema which persists without much tendency 
to exudation, Lupus erythematoides of Leloir. According to I'nna. the more 
common cases of this form have two marked tendencies : 1st. To the forma- 
tion of crusts (lupus crustosiis) from sero-fibrinous inflammation, or less 
often hyperplastic growths, especially of the epithelium (lupus verrucosus), 
and 2d. To more rapid extension at the periphery, and largely due, in either 
case, to the rich blood supply always present. 




Fig. 104— LUPUS VULGARIS 

EXFOLIATING TYPE 

Patient, a German woman of twenty-five years. Duration of disease twenty 
years. Started as a small spot and spread slowly until the whole left cheek is 
involved. The nodular feature has disappeared and an exfoliating retrogressive 
state has commenced. Practically all known methods of treatment have been tried, 
including phototherapy, high frequency currents, static sparks and radiotherapy, with 
the results that the condition is slowly improving. 




Fig. 105.— LUPUS VULGARIS 

NODULAR TYPE OF THE EAR 

Same patient as Fig. 104. This lesion, how- 
ever, is nodular, and in the active part of its 
course. Duration, five years. Under the use of 
the X-rays, the size of the patch has been re- 
duced by one-half. 



LUPUS VULGARIS B65 

As a rule, lupus vulgaris occurs in a single patch, but occasionally it 
appears in multiple patches, either at one time, or at long or short intervals, 
and rarely the distribution may be wide or general, Lupus disseminatus. In 
the stages of evolution the lupus nodule and erythema may be associated in 
varying degree, and may continue into the retrograde stage of resorption, 
fibroid or cheesy degeneration, while to these may be added, early or late, 
one or more of the products of inflammation or hypertrophic growth. The 
pathological and clinical features are also determined somewhat by the local- 
ization. 

The face is the favorite seat of the disease, especially the nose and adjacent 
part of the cheeks. Most often it begins at the alse of the nose and progressively 
destroys the skin and cartilage, giving to the nose a hacked-off appearance. 
In other cases it may extend all over the nose, or beginning at the root near . 
the eye it may remain confined to that region, gradually destroying the parts 
down to the bone, the eyelids and even the eyeball. Occasionally the disease 
may begin in the mucous membrane of the nose and appear at the outer part 
of the nostril later, but the bones of the nose are rarely attacked as in syphilis, 
and the "caved-in" appearance of the bridge, due to the latter, is not seen. 
Sometimes in an advanced stage crusts and papillary growths may give a 
look of increased size to the nose, but on the removal of these, the cutaneous 
parts of the nose and cartilages may be found nearly or quite destroyed. Other 
parts of the face are frequently attacked secondarily or less often primarily. 
The extremities are common seats for the disease, especially the spread- 
ing form, and on the lower Hmbs particularly is likely after a time to produce 
mixed tissue changes and more or less deformity. These phenomena arise, 
subsequent to the deposit of lupus growths, from repeated attacks of der- 
matitis, phlebitis, lymphangitis, etc., and occur chiefly on the arm below the 
elbow or more often on the leg below the knee. The lupus nodules along the 
lymphatics may degenerate into flabby ulcers, periostitis over the superficial 
joints and bones of the hands and feet may occur, with subsequent caries and 
necrosis of these parts. Later extensions and contractions may produce a 
pseudoanchylosis of the joints, or disease of the periosteum and bones con- 
sequent to lupus of the outer parts may result in destruction of portions of 
the fingers, which, together with the retraction of other fingers or parts, produce 
deformities sometimes almost as terrible as the mutilation of leprosy. At the 
same time, as the result of inflammations and contractions in the tissues 
of the limb affected with lupus, there may be produced more or less persistent 
venous and lymphatic stasis with consequent oedema, thickening and hyper- 
troplry amounting to a condition of elephantiasis. 

On the trunk lupus is apt to be superficial, but more extensive than on 
other parts. Over the nates secondary changes into papillary and elephan- 
tiastic forms are likely to follow or the ulcerating serpiginous type may alone 
appear. 

Lupus of the genitals is rare in either sex, and nearly always the result 
of extension from adjacent regions. Kaposi has met with it situated ex- 



366 LUPUS VULGARIS 

elusively on the penis and scrotum. Some reported cases of lupus of the vulva 
are believed now to have been of a different nature. 

Lupus may find a location on any region of the body, but as Hutchinson 
has noted, it is the least likely to occur in the warmer parts of the skin. In 
Austria where the disease is quite common extensive involvement of the integu- 
ment is not rare, and even generalized lupus vulgaris has been observed. In 
America the disease is far less frequent, and is seldom found with isolated 
lesions in more than one region, and then very rarely shows any tendency 
to symmetry in distribution. 

Lupus of the mucous membranes may occur independently of the cutaneous 
disease or may be secondary to it. Probably it is more often secondary in 
order of occurrence, though Neisser believes that lupus of the face, especially 
the nose, can be generally traced to pre-existing lupus of the neighboring 
mucous surfaces. Leloir's records show that associated lupus of the mucous 
stricturesjs present in over one-third of the cases of the cutaneous lupus. On 
the mucous surfaces the lupus growth is represented by single or multiple, 
well-defined, granulating patches or papillary outgrowths of a reddish, whitish 
or grayish color of variable size, and changing slowly (after months or years) 
into ulcerative or cicatricial processes. The buccopharyngeal and laryngeal 
membrane are affected more often than the tongue. The gums may be more 
or less covered with granulations, spongy and bleed easily, and the teeth loosened 
and fall out. Laryngeal lupus is quite rare, and when present nearly always 
involves the epiglottis. Hoarseness is usually an early symptom, and in ex- 
ceptional cases coexisting inflammation (chondritis and perichondritis) and 
oedema may prove to be serious complications. These conditions, however, 
very rarely prove directly fatal. Enlargement of the lymphatic glands occurs 
oftener than in cutaneous lupus, and in either case Leloir looks upon the 
glandular involvement as an evidence of secondary infection which may lead 
to pulmonary tuberculosis. 

Lupus of the skin, as a rule, begins primarily at an early age, which is 
given by Kaposi as from the third to the sixth year. It is likely to be more 
active in childhood, but may spontaneously disappear after a variable number 
of years, leaving behind atrophic scars. Many years later fresh lesions may 
develop in these cicatrices, or at new points, and thus the disease may appear 
to begin in middle or later life. In some cases it may persist from child- 
hood or youth to old age, never quite disappearing ; others may be characterized 
by exacerbations and remissions in the activity of the process. 

Physiological changes in the system, acute diseases, exposure to cold, etc., 
may influence the course of lupus, which in any event is apt to be extremely 
chronic and variable, but generally tends to be less active with advancing age. 
It is usually unattended with painful sensations, but coexisting inflammation 
of the affected or surrounding tissues may give rise to heat, burning, itching 
and tension of moderate degree. The disease seldom appears to have any effect 
upon the general health, except in an indirect way and in unusual cases. 

Etiology. — As auto-inoculation is the usual mode of infection in orifi- 



LUPUS VULGARIS 8fl! 

cial tuberculosis, and direct inoculation in verrucosa tuberculosis, so indirect 
inoculation appears to be the ordinary mode of origin of classical lupus 
vulgaris. Exceptionally it may be due to direct infection as the other forms 
may with like exception arise from indirect inoculation. The avenues of 
indirect infection may be scrofulous lesions of the superficial or deeper I issues 
(glands and bones), possibly at some distance by means of the lymphali 
In three hundred and twelve cases of lupus Leloir found forty-one had followed 
subcutaneous tuberculosis, thirty-two tuberculosis of the glands and twenty- 
nine tuberculosis of the joints and bones. Such evidence shows more than 
a coincident relation to the strumous diathesis. The coexistence of lupus 
and pulmonary tuberculosis has been abundantly proved by Haslund, Leloir, 
Eenouard, Besnier and others, but the causal relationship, or order of occur- 
rence, has not been established in a conclusive degree. Crocker says he has 
been astonished " at the large proportion of cases in which a history of 
phthisis in one or more members of the family is obtainable." 

Children and females are much more prone to the disease than male 
adults. Probably because the surface tissues of women and children are more 
sensitive and susceptible to irritating organisms, and because they more readily 
communicate the disease by their more intimate contact with each other in 
the ordinary relations of life than is habitual with the male sex after maturity. 
While many hold to the belief that lupus rarely originates after puberty, 
remaining in some cases long inactive and unobserved, there are occasionally 
instances of the disease beginning so late in middle life as to make the theory 
of invariable early infection improbable. At the same time there is little 
doubt that any break in the continuity of the skin from accident or disease in 
early life may afford a starting point for a process which, under favoring 
conditions, may remain dormant for an indefinite period. 

The most advanced pathology of circumscribed lupus supports this sup- 
position. Unna states that the same appearance may exist in the lupus nodule 
after many years as after a few months, and that after certain cellular 
transformations have occurred it may remain long unchanged if unaffected by 
any external irritant. " A balance is established between the action of the 
poison and the reaction of the skin; the tubercle bacilli have thrown up a 
wall around them inside of which they repose, latent but not dead." In the 
diffused form of lupus the cellular changes are comparatively insignificant, 
the hyperemia pronounced, and extension of the process is nearly continuous 
and sometimes rapid. Hence the nearer a case approaches this type of the 
disease the less is latency a clinical feature. 

Lupus invariably begins in the corium and works outwardly to the surface. 
To the number and activity of the bacilli and the reaction of the dermal tissues 
in different persons in different regions of the body, at different times, and to 
the secondary changes thereby induced in the different parts, with or without the 
aid of other infections, all the pathological features of lupus are due. These 
will be referred to briefly hereafter. Clinically, pure types are seldom seen 
throughout, but incline in varying degree to the circumscribed or diffuse form. 



368 LUPUS VULGARIS 

Diagnosis. — The differential points relating to lupus vulgaris are — its 
usual beginning in childhood or youth, indolent and painless course, frequent 
situation on the face (especially the nose), red, yellowish-red or violet colored 
erythema, soft papules or jelly-like nodules and frequently presence of other 
signs of tuberculosis ; and if an ulcer forms it is usually superficial, with soft 
edges and soft granulating floor, scanty and inoffensive secretion and the crusts 
usually thin and brownish. The soft "apple jelly" nodules imbedded in the 
skin or raised above it are pathognomonic, but in their absence seldom will a 
case be found which does not present some of the diagnostic points mentioned. 

Syphilis of the skin and mucous membranes may be distinguished from lu- 
pus by its usual origin in adult life, history of primary infection and traces of 
other lesions, its much more rapid course, often destroying in weeks more tissue 
than lupus usually would in years, sometimes attacking bone early which lupus 
does not affect at all or only late. The syphilitic ulcer is more apt to be 
multiple, wider, deeper, with more sharply cut edges, offensive discharge and 
abundant greenish crusts. Lastly, delay in diagnosis and treatment of doubt- 
ful cases for a few weeks may show new lupus nodules developing on the one 
hand, or on the other antisyphilitic remedies lead to a rapid improvement of 
the ulceration. 

Scrofuloderma, like a syphilide, will be likely to show other signs of the 
disease in the shape of linear scars, caseous glands, sinuses, with more ulcer- 
ation and undermining of the skin than occurs in lupus, but an absence of 
the lupus nodule. It is to be remembered that lupus and scrofuloderma may 
coexist, and as they are closely related a positive diagnosis is not very im- 
portant. Generally, however, they can be differentiated without delay. 

Epithelioma may be confounded with lupus, but the former is usually a 
disease of advanced life, is painful, its ulcer is often deeper, with an uneven 
floor and hard, everted edges. While it is limited to a smaller area, its progress 
is finally more rapid and the glands are more frequently involved than in 
lupus. An epithelioma may originate in a chronic lupus patch and the two 
diseases exist together. The smooth floor and indurated border of rodent ulcer 
occurring late in life will distinguish that disease. Non-tuberculous lupus 
erythematosus may be distinguished from lupus vulgaris by its usual appearance 
after puberty, symmetry in distribution, superficial character without soft 
nodules or tendency to ulceration. Occasionally oedema may mask the lesions 
of tuberculous lupus and sometimes the differences between the two forms of 
lupus are very slight. Nearly always, if the adherent crusts of lupus erythe- 
matosus are removed, the widened opening of one or more sebaceous ducts will 
be revealed, corresponding to little projections on the under surface of the 
crust; such conditions never exist in lupus vulgaris. 

Squamous eczema, and seoorrhoeic dermatitis might be confounded with 
lupus, but the presence of apple-jelly nodules, a sharply defined elevated bor- 
der, absence of moist exudation or marked variation in intensity, slow course 
and tendency to scar formation will always enable one to distinguish lupus 
from the first named diseases. 







Fig. 106.— LUPUS VULGARIS 

ULCERATING AND EXFOLIATING VARIETY 

Patient is a woman of forty-five. Disease began twenty-two years ago as a 
small nodule on the side of the nose opposite the left eye, where it remained, little 
changed, for ten years. Twelve years ago an outgrowth appeared and progressively 
extended over the side of the nose, leaving a hard exfoliating surface behind the 
elevated advancing border. The original lesion became the site of an ulcer which 
crept superficially over the root of the nose and at the inner angle destroyed the 
deeper parts and a portion of the eyelids. Sore, burning sensations are aggravated 
by touch and washing the parts. Great relief followed the continued use of arsen- 
icum iodatum, third decimal. 




Fig. 107.— LUPUS VULGARIS 

ELEVATED NODULAR VARIETY 

Patient, a man aged fifty. General health good. No cancerous or tubercular family 
history. A small red spot appeared on the right supra-orbital region twenty years ago, 
and has spread steadily until the growth has a width of three inches. Thirteen years 
ago two operations for removal were performed in Germany, but the disease returned. 
After eighteen months' treatment, first with the Finsen rays and then with the X-rays, 
the lesion has practically disappeared. 



SCROFULODERMA 369 

In the early stage of tubercular or mixed leprosy some resemblance to lupus 
might exist. The history of residence in a leprous country and the presence 
of local anaesthesia would help to establish the presence of leprosy, while later 
developments would bring out other characteristics of that disease. 

Prognosis. — Lupus seldom directly destroys life, and the danger of sec- 
ondary tubercular infection, though possible, is not great. The tendency of 
the lupus nodule to recur stands in the way of permanent recovery. This 
tendency can be greatly modified by indicated remedies employed in connection 
with germacidal or other local methods. It follows that the prospects of cure 
depend, in a measure, on the continuance of treatment adapted to the individual 
case. A scar is to be expected in all cases and should be included in the forecast. 



D. SCROFULODERMA 

Definition. — A tuberculous affection of the skin originating chiefly in 
the subcutaneous tissue, lymph glands or from tuberculous bone (osteomye- 
litis), followed by infiltration and softening and resulting in the formation 
of ulcers. 

The scrofulous type of tuberculosis is probably the most common of all 
forms, and has been known as scrofulous inflammation, scrofulous gumma, scro- 
fulous abscess, scrofulous sores, etc. It produces a variety of lesions of the skin, 
differing according to their seat, the state and the extent of the tissues affected. 
They may be conveniently grouped under (1) subcutaneous, and (2) cutaneous 
scrofuloderma. 

Subcutaneous scrofuloderma often begins in the superficial lymphatic 
glands, especially about the neck, under the jaw, at the side or in the clavicular 
region. Less commonly it starts as one or more nodular or cork-like infiltra- 
tions in the subcutaneous or perilymphatic connective tissue. The resemblance 
to syphilitic gummata led Besnier to call these infiltrations scrofulous gum- 
mata, and Unna has termed them subcutaneous scrofulous gummata. 

The skin over these painless swellings is at first movable and normal in 
color, and they may undergo little apparent change for some time. Ulti- 
mately, as a rule, softening occurs, forming a cold abscess, and the skin involved 
by the upward growth and from pressure becomes thinned, first red and then 
of a bluish hue. Finally, rupture of the cutaneous covering takes place and 
gives exit to a watery pus mingled with caseous matter and blood. Thus a 
chronic scrofulous ulcer is formed varying in depth and extent with its origin 
and course. The degenerative process may extend downwards to the cartilage 
and bone, especially when the lesions are on the extremities. Sometimes they 
originate from an osteitis of the bones, which, according to Lyons, may be latenb 
in some cases and their osseous origin easily overlooked. The fistulous tract 
from an internal focus discharges a similar fluid containing necrotic tissue, 
etc., as the degenerating gumma, but its appearance externally varies with the 
extent of the scrofulous inflammation and the dimensions of the fistula. 



370 SCROFULODERMA 

Often the opening is small with thin, bluish, transparent lips. Sometimes the 
bone of one or more fingers may be encased by the scrofulous infiltration, and 
caries of the bone occur, constituting a form of strumous dactylitis, which, 
in its further progress, may develop multiple fistulous openings on the surface 
with or without papillary and fungating growths. Bulbous extremities of 
the fingers and toes generally seen in children is another form of scrofulous 
dactylitis. 

Occasionally in old people, who may show the scars of scrofuloderma of 
early life, strumous ulcers take on a papillary hypertrophy identical with the 
lupus papillomatosus of lupus verrucosus, thus illustrating the exceptional 
transition of a scrofuloderma into a lupus. The relationship of the two 
varieties of tuberculosis is further shown, in the reverse order, by the occa- 
sional development from lupus of scrofulo-gummata of the lymphatics and the 
consequent scrofulous ulcer. 

Indeed, Unna asserts that subcutaneous forms of scrofuloderma nearly 
always originate from tuberculosis of the lymphatics of the subcutaneous tissue. 

A form of subcutaneous infiltration described first by Bazin as- erytheme 
induredes scrofuleux, and in this work called erythema induratum, is probably 
an unusual form of subcutaneous scrofuloderma. 

The cutaneous type of scrofuloderma more often originates on the skin 
over caseating or softened lymphatic glands. The skin soon becomes red, 
doughy or flabby and undermined, sometimes riddled with openings which 
may extend to the gland beneath. Less frequently there is no apparent con- 
nection with the lymphatics, and flatfish, ill-defined thickening of the skin 
occurs, of reddish-brown color, soft spongy consistence, gradually raised above 
the surface into a roundish or oblong, flat tumor varying in size from a pea 
to a walnut. It does not so readily soften as the first named and may dis- 
appear by absorption, leaving a red spot to mark its site for a long time. 
Both forms, constituting the cutaneous scrofulous gummata of Unna, usually 
undergo gummatous softening and spontaneously evacuate their contents, if 
not previously incised, and may then slowly heal or more often leave a super- 
ficial spreading ulcer showing little tendency towards repair. "Untreated these 
ulcers may spread in one or more directions or, undermining the epidermis, 
small ulcers may appear with connecting sinuses extending from one to an- 
other and invading a larger extent of the surface of the affected region. Bur- 
rowing forms of scrofuloderma may open cylindrical pockets or more often 
sinuses of communication with either deep or superficial lesions. 

Cutaneous scrofuloderma is the more common persistent and true type 
of the disease, but the two forms may occur in any degree of association and 
present a variable external appearance accordingly. The most typical scrofu- 
lous ulcer varies from the linear to oval in shape, with a grayish, uneven floor, 
covered with flabby granulations and secreting a watery pus. If the base is 
examined it may be found yielding or firm, but is never hard. The edges 
are generally undermined, thin, soft, pale or bluish, sharp cut or ragged and 
often inverted so as to nearly or quite hide the ulcer underneath. The crust 




Fig. 108.— SCROFULODERMA 



Patient, a young man of twenty-five years, with a pronounced tubercular family 
history. When about ten years old, he had a tubercular condition of the right elbow- 
joint with abscess formation and sinuses. A deep ulcer developed on the extensor 
surface two inches above the tip of the elbow. The marked scar shown in the illus- 
tration represents the seat of this ulceration, which took five years to heal. The 
active lesions are superficial pustules and warty nodules grouped about the elbow 
joint. A cure of this last mentioned patch was obtained with arsenicum. iodatum, 
third decimal, and by painting the affected surface with a solution containing 
two grains of the bichloride of mercury and ten grains of resorcin to an ounce of 
collodion. 




Fig. 109.— SCROFULOUS DACTYLITIS 



BULBOUS VARIETY 

Patient is a child of eight, with a tubercular family history. 
The personal history indicates that symptoms of scrofuloderma 
appeared about three years ago, and that in the subsequent in- 
terval swelling of the fingers has gradually occurred; attacks 
of sore throat with swelling of the tonsils have also been com- 
mon. Treatment: Fresh air, sunlight, a generous diet, and 
baryta iod., sixth decimal. 



SCROFULODERMA 37 1 

formed by the secretions from an ulcer if of large size may be thick or rupioid 
in form; nearly always it keeps the shape of the ulcer covered, is thin, ad- 
herent and brownish. Clean cut, flat strumous ulcers are occasionally seen 
in old people; they seldom heal spontaneously and are liable to develop into 
rodent ulcer or other form of epithelioma. Sometimes they become papillo- 
matous, especially when situated on the back of the hands, and are exceedingly 
chronic. 

The course of scrofuloderma as a whole is always slow, and when an ulcer 
has formed it rarely manifests any tendency to heal; on the contrary, may 
progressively spread. Before ulceration occurs, the tuberculous tissue may 
become encapsulated and hold stationary, or, with great rarity, absorption may 
take place. 

Where healing occurs the resulting scars are linear or irregular, often 
corded, sometimes net-like and isolating portions of scrofulous tissue or small 
areas of sound skin. These cicatrices may be of diagnostic value in later years. 

The most common location of scrofuloderma is about the neck, as before 
mentioned, but it is not uncommon on the face, shoulders, hands, in the groin 
and may occur elsewhere. Almost always the well-known scrofulous physique, 
or local sign of the scrofulous taint, will be found in patients exhibiting some 
of the scrofulo-dermata, though the general health may appear fairly good 
and the cutaneous lesions give rise to little or no suffering. 

Among cutaneous forms of scrofulosis should probably be placed lichen 
scrofulosum, acne scrofulosum (acne cachecticorum) and the rare pustular 
scrofuloderm of Duhring. But inasmuch as the etiology of these affections 
is undetermined, they may be looked upon as dermatoses of the scrofulous, 
the product of a mixed infection. Lichen scrofulosus will be briefly described 
under a separate heading. In typical form it is seldom or never seen in this 
country. Acne scrofulosus and acne cachecticorum are essentially the same 
affection and in the nature of a folliculitis occurring in the scrofulous. The 
eruption is said to sometimes occur in association with the lesions of lichen 
scrofulosus. It is less rare than the latter, and usually appears on the trunk, 
extremities and sometimes on the face in the form of mustard seed to pea-sized 
or larger, dark red, flatfish and flaccid papulo-pustules. They contain a com- 
paratively small quantity of sero pus which dries into crusts ; hemorrhage may 
occur in some of the lesions, giving them a livid appearance or surrounding 
them with purplish halos. Underneath the crusts ulceration takes place and 
when repair occurs the resulting scars remain for a long time livid or purplish 
in color. While more often seen in children with other evidences of scrofula 
they may appear in the cachectic or scrofulous at any age, and are sometimes 
secondary to other cutaneous eruptions, such as seborrhceic dermatitis and 
eczema in the strumous. Barely a similar eruption is seen upon the extremi- 
ties apparently unconnected with the scrofulous cachexia or any discoverable 
cause. 

The large and small pustular scrofuloderm described by Duhring as well 
as the form of scrofuloderma mentioned by Yon Harlingen and characterized 



372 ETIOLOGY AND PATHOLOGY OF TUBERCULOSIS CUTIS 

by the small number of lesions and extreme chronicity may be considered as 
rare variations from the more usual type of acne scrofulosus. I have observed 
two cases in adults in which the eruption appeared on the forearms and legs 
below the knees, in which not more than two or three flat, hard, split-pea sized 
papules (less often papulo-pustules), surrounded by a violet areola, appeared 
at one time. Each lesion slowly crusted over and covered a small scrofulous 
type of ulcer, which finally healed, leaving a pit-like cicatrix very like acne 
varioliformis. One or more new lesions formed while the old ones were in- 
voluting or healing and in each instance pursued the same indolent course. 
Both cases exhibited evidences of early scrofula and both had persisted for 
: years, one for five years when first seen. Neither was attended with pain or 
discomfort. 

The diagnosis of scrofuloderma may be made usually without difficulty. 
The absence of the characteristic lupus nodules will distinguish it from that 
disease. The two types of tuberculosis occasionally coexist. Then the ulcers 
are apt to be deeper, the crusts thicker, darker and more conspicuous. 

From syphilitic ulcerations scrofulous ulcers may be differentiated by their 
usual occurrence in early life, slower course and the presence of other signs of 
struma. The ulcerating syphilide generally appears in adult life, is more 
rapidly destructive and other evidences of syphilis are often obtainable. 

The prognosis as regards the local lesions is favorable. Nearly all may be 
made to heal under treatment. The scrofulous habit may also be greatly modi- 
fied by indicated remedies and physiological methods. 

Special Etiology and Pathology of Tuberculosis of the Skin. — 
Something has already been said regarding the mode of infection leading to 
orificial tuberculosis, verrucose tuberculosis and lupus vulgaris, designated as 
auto-inoculation, direct inoculation and indirect inoculation, respectively, while 
scrofuloderma is probably a secondary form of tuberculosis. There is little 
doubt to-day that in all of these types of cutaneous disease the tubercle bacillus 
is the sole efficient cause. It is not by any means determined how entrance to 
the cutaneous and subcutaneous tissues is gained in all cases, or what peculiar- 
ities of the virus itself or the tissues attacked influence the form of the subse- 
quent process. The product of the bacilli, the nodule of granulation tissue, 
composed of so-called giant cells, small round cells and epithelial cells, unstable 
in character and ultimately undergoing central necrosis or cheesy degeneration, 
once thought pathognomonic of tubercle, are now known to occur in other patho- 
logical conditions without the presence of the bacilli of tuberculosis, and cannot 
always be differentiated histologically. The pathology of orificial tuberculosis 
corresponds closely to the process in pulmonary tuberculosis, e.g., formation of 
typical miliary nodules, caseation, softening and ulceration. In such lesions the 
tubercle bacilli are comparatively abundant. 

In tuberculosis verrucosus the tissue environments of the bacilli- are not 
usually favorable for extension of the disease. This is due in part to the 
location in regions where the epidermis is relatively thick and the cutis rela- 



PATHOLOGY OF TUBERCULOSIS CUTIS 373 

lively thin and ansemic. The epidermis is stimulated to proliferate and in- 
creases in volume without suffering injury in structure by the disease being 
limited almost always to the papillary layer of the cutis and sometimes to 
the papillae. The bacilli are said to be less abundant than in the orificial form 
and more numerous than in lupus, but usually more superficially situated than 
in either. 

In lupus the pathological process is a much variable and complex one 
than in the two forms just mentioned and gives rise to a variety of clinical 
expressions briefly described under the symptoms of lupus. The primary seat 
of the morbid process is usually in the deeper part of the corium and extends 
its foci of disease outward towards the surface. 

On a histopathological basis Unna divides lupus vulgaris into two main 
forms: (1) Lupus circumscriptus, nodulosis; (2) Lupus diffusus, radians; and 
the further changes in these forms, due partly to the tubercular virus and 
partly to secondary processes, set up: (a) epithelial hypertrophy (synonymous 
with verrucose growth) ; (b) acute inflammation of lupus; (e) fibrillary scle- 
rosis of lupus; (d) secondary suppuration and liquefaction of lupus and (e) 
absorption of lupus. 

In lupus circumscriptus the elementary nodule is present in its most 
characteristic form. At the seat of these nodules in the corium, composed of 
closely packed cells (granulation tissue), the elastic fibres, the blood and 
lymph vessels are absorbed or pushed aside and the line between the normal 
and diseased area is sharply drawn. Within the nodule groups of cells are trans- 
formed into giant cells and every giant cell sooner or later consists of two parts, 
a growing and a degenerating part, and when it has reached its height of 
evolution degeneration predominates and regressive changes characterize the 
process thereafter. Giant cell transformation of the lupus nodule having 
taken place, it may remain unchanged for years before apparent breaking down 
occurs. 

In lupus diffusus the process is not so specific of tuberculosis as in the 
nodular form, and there is only a scant grouping of cells, often in rows, with 
only slight transformation into giant cells. This is due in part to the character 
of the tissues involved. Beginning in the sub-papillary layer of the corium 
the cell growth chiefly develops from the perithelium of the blood-vessels and 
simple connective tissue cells, and radiates in net-like processes into the 
papillary body, the follicles and glands, in a minor degree about the inter- 
cellular bundles of the connective tissue and finally penetrates the fatty tissue 
without forming at any point distinct circumscribed areas. Consequently 
giant cell formation does not take place except in small number and at very 
limited points in the centre of the area affected. Diffuse lupus seldom exists 
in a pure form, but as modified by or modifying the circumscribed form in 
variable degrees and as influenced by inflammatory and hypertrophic processes 
secondarily set up by the tuberculous infection. 

Aside from the pronounced epithelial hypertrophy already noted in tuber- 
culosis verrucosus, more or less atypical changes occur in all cases of diffuse 



374 PATHOLOGY OF TUBERCULOSIS CUTIS 

lupus, not only in the main body of the prickle layer, but in the coil glands, and 
to a less extent in the hair follicles and sebaceous glands. These do not give 
rise to clinical manifestation and are of histological interest only. 

The acute inflammation which occurs chiefly in diffuse lupus, is sero- 
fibrinous in nature, induced by the bacillogenous products and the over abun- 
dant blood supply. To the latter condition of dilated capillaries, mainly at 
the surface of the lupus, the limitation of the exudation to the outer epithe- 
lium is due, while the deeper epithelial processes further removed from the 
vessels may be little affected. This acute inflammation may, in the case of 
encapsulated lupus nodules, lead to moderate central necrosis, but not to sup- 
puration, and the pathological differences between the crusted lupus from sero- 
fibrinous inflammation and from secondary suppuration appear distinct. 

In fibrillary sclerosis of lupus the origin of the fibrous change is in the 
normal connective tissue which surrounds the nodular and in a less degree the 
diffuse'lupus growth. This change is not strictly a fibroid degeneration, but 
a growth of fibrous processes in a horizontal direction into the tuberculous 
nodule, ultimately replacing it to a large degree by inducing absorption of 
some and possibly restitution of other parts of the growth. If the fibromatosis 
is not excessive it forms the lupus cicatrix, or if the process continues to ex- 
tend beyond the area of lupus deposit, firm, deep or keloid-like, reddish swell- 
ings may develop or there may ensue a transition into a more dense general 
tissue hypertrophy, or new growth, known as sclerotic or elephantiasic lupus. 

The pathology of so-called suppuration and liquefaction of lupus is not well 
understood. Unna doubts the existence of any true suppuration, i.e., due to 
the action of pus cocci or the existence of a mixed infection. He inclines 
rather to the view that in the rare cases of lupus vorax and lupus phagedenicus 
there is a secondary infection of unknown nature, or of a peculiarly strong 
idiosyncrasy of the tissue to the action of the poison which causes a rapid 
liquefaction of the skin. 

The absorption of lupus has been referred to as occurring from compres- 
sion following ingrowths of fibrous processes into the lupus tissue, but there 
is no true resolution, fibrous tissue always forming to some extent and pro- 
ducing a scar. "When the process permits some restoration of normal tissue 
into the part with only a small amount of fibrous tissue, cicatrization is the 
least conspicuous. In all these cases the absorption or complete disappearance 
of lupus tissue is uncertain, and may be followed in a longer or shorter time 
by a recurrence of the disease. 

The pathology of scrofuloderma of the subcutaneous tissue resembles nodu- 
lar lupus up to a certain point in development. Beyond a characteristic in- 
tercellular necrosis occurs which leaves the nuclei unaffected or only slightly 
changed for a long time if not altogether, unlike coagulation necrosis. The 
necrotic process may be changed somewhat by the presence of a moderate num- 
ber of leucocytes, so that it may appear different in different parts. Scrofulo- 
derma is roughly distinguished in its pathology from other forms of tuberculosis 
of the skin by its secondary origin from some internal source, and its beginning 



TREATMENT OF TUBERCULOSIS CUTIS 876 

in the subcutaneous tissues, where the bacilli find perhaps better protection 
and nourishment amid tissues less capable than the cutis of resisting their 
primary pathogenic action. 

Treatment of Tuberculosis of the Skin. — In view of the etiology 
of tuberculous processes affecting the tissues of the skin, the importance of 
preventive measures can be fully appreciated. Sufferers from any form of 
tuberculosis do not need to be isolated or deprived of the reasonable social 
pleasures of society, but they should be made to understand that so long as 
their disease exists and gives origin to or pollutes secretions or discharges 
they may be a possible source of contagion to others. This applies especially 
to cases of pulmonary tuberculosis so constantly prevalent nearly the world 
over. Sputum and all other secretions from tuberculous lesions should be 
sterilized and burned (not buried) when possible. Those who mingle fre- 
quently or constantly with the tuberculous as well as the tuberculous them- 
selves should care for slight abrasions or eruptions, especially of exposed parts 
of the surface, by protecting them with antiseptic or occlusive dressings 
until healed, and accidental contact of even the sound skin with infected 
discharges should be followed immediately by cleansing with antiseptic solu- 
tions. Early germicidal treatment of wounds or lesions of the surface sus- 
pected of having been infected with the tuberculous virus should be thorough, 
sometimes to the point of saturation of affected tissues, thus aborting a possi- 
ble beginning of chronic tuberculosis. 

The value of internal prophylaxis for those who manifest hereditary or 
acquired tendencies to disease, especially the scrofulous habit, needs only 
mention. The utility of fresh air, sunlight, outdoor living, a suitable diet, 
regular exercise, cleanliness of body and mind, etc., comprehended as physio- 
logical living, in fortifying the organism against the onset of germ diseases, is 
well known. Add to these methods the indicated prophylactic remedy which 
may act more directly on the seat of all vitality, the protoplasmic cells, and it 
seems more than probable that a high degree of immunity can be established 
against many forms of disease. 

The treatment of existing and active tuberculosis of the skin is best con- 
sidered under (1) external treatment, and (2) internal treatment. 

I. External Treatment. — Here we must remember in the first place 
that we have to deal with a germ disease, and that to the extent that we can 
destroy or limit the action of the micro-organism to that extent we remove 
the efficient cause and promote the cure. Furthermore, it is a destructive 
disease, often attended with inflammation and followed in favorable cases by 
the formations of fibrous or cicatricial tissue, and if it becomes necessary to 
artificially destroy tissue, excite inflammation or promote fibrosis, art bore 
simply follows in the footsteps of nature. When tuberculosis of the skin is 
latent or inactive, as in some cases of encapsulated lupus remaining stationary 
for years, it is doubtful if local treatment is called for, but the moment activ- 
ity begins or reigns it should be inaugurated and continued with judicious 
persistency. 



376 TREATMENT OF TUBERCULOSIS CUTIS 

Since the etiology and pathology of the skin have become better known, 
many of the more severe methods of local treatment have been largely aban- 
doned; some have become nearly or quite obsolete and will not be mentioned 
here, while others little employed will be only briefly referred to. Choice will 
generally lie between the use of phototherapy, radiotherapy and parasiticides. 
Possibly all may be necessary in the treatment of any one case. Orificial 
tuberculous ulcers may be induced to heal as a rule by application of germi- 
cides in solution. I have seen rapid healing of these ulcers under the influence 
of cleansing with hot water (as hot as can be borne), drying the surface 
with antiseptic cotton and immediately thereafter painting the surface of the 
ulcer and slightly beyond with a solution of two to eight grains of corrosive 
sublimate in an ounce of compound tincture of benzoin. The treatment can be 
repeated daily or oftener and the strength increased from. the weaker to the 
stronger solution as required. When healing has progressed to a considerable 
degreeiiolomol-boric acid, twenty per cent., or aristol, ten per cent., will serve 
as an antiseptic protective. 

Tuberculosis verrucosa of small or moderate extent may be covered with 
a paste composed of salicylic acid and glycerine spread on a cloth, or with 
TJnna's strong salicylic acid and creosote plaster, and after the thickened epi- 
dermis has been softened and destroyed it may be painted twice daily with the 
solution of corrosive sublimate above named. In the interval between the 
applications, the surface can be covered with thin silk isinglass plaster, which 
is easily removed by wetting it with warm water. As the growth diminishes 
in size it may be painted freely with iodine and then varnished over with col- 
lodion at intervals of a few days. Boring into the growth with a pointed stick 
of nitrate of silver, after the epidermis has been removed with the salicylic 
acid, has been advised. I have never found it needed in verrucosa necrogenica 
or other warty tuberculous growths; neither have I employed curetting in 
similar cases, though either may be of service in making a more rapid cure, 
with the after use of antiparasitics. Isolated warty growths on the unexposed 
portions of the skin may be removed by excision carried well beyond the 
affected area. The larger scar resulting from this surgical method makes it 
more objectionable for lesions situated on the uncovered parts of the surface. 

Lupus vulgaris may be treated by phototherapy, and it is the best single 
method for most cases. Finsen of Copenhagen and his followers have demon- 
strated scientifically the worth of this form of light treatment. The records 
of the first 800 cases of lupus vulgaris treated in Finsen's Lysinstitute in 
Copenhagen, show that eighty-two per cent, were entirely cured or showed very 
slight traces of the disease. The apparatus and general technique will be found 
under the heading of phototherapy in Part I. Since deep penetration of the 
light is necessary, the exposures may need to exceed an hour. An inflamma- 
tion develops which reaches its climax in one to two days. The eruption is 
mainly of a vesiculo-bullous type. When this reaction subsides, which may be 
in seven to fourteen days' time, another treatment is given. This routine is 
continued until all the lupus nodules disappear, but the patient should be 



TREATMENT OF TUBERCULOSIS CUTIS 377 

carefully watched for some months afterwards. Usually from one to six treat- 
ments will suffice for an individual patch, but generalized or extensive lupus 
may necessitate daily exposures, because so many different areas must be 
treated. All obstacles to the penetration of the light such as crusts should 
be removed, even if it is necessary to employ ointments for that purpose. In 
a fair percentage of cases which present extensive pigmentation, thick scars, 
or deep infiltration, or are so situated that pressure and direct radiation is 
impossible, radiotherapy is better adapted. Also many cases are unable be- 
cause of their means or residence to receive the Finsen light treatment, while 
the Rontgen rays may be found everywhere. The X-rays may produce just as 
good cosmetic effects and destroy the nodules as thoroughly as the Finsen rays ; 
but to be effective a dermatitis must be developed, which may persist for 
weeks, causing pain and a suspension of treatment. The editor has observed 
good results from the use of the Rontgen rays in cases of circumscribed lupus 
of the forehead, the ear and the back ; but with the superficial variety of the 
trunk nothing has been more satisfactory than radium (200,000), applied 
every other day for ten to thirty minutes. Five treatments sufficed in one case, 
twelve in another and about thirty greatly relieved in a third instance. Of 
course, the lack of sufficient quantities of radium of a definite radio-activity 
precludes the chance of achieving wholly satisfactory results, and, its action 
being similar to the Rontgen rays, it cannot be said to present any advantages 
over it. 

Parasiticides are successfully used in many cases, and while they possess 
antiparasitic power in common, they are sufficiently different in their effect 
on tissues to make a choice of one rest on something more than the fancy of the 
prescriber. Scales and crusts may be softened and removed by applications 
of any mild antiseptic ointment or by poulticing if needed, so that more 
energetic applications may come in direct contact with the tissues. When 
there is epidermic proliferation and hypertrophy, salicylic acid, from its power 
of dissolving epithelium, is useful. It may be used in the manner indicated 
above for warty formations, but not in too concentrated form when the thick- 
ening of the epidermis is moderate. Combined with carbolic acid, in the pro- 
portion of thirty drops of the latter to an ounce of the base, it is less painful 
in its action, though the pain is not usually of long duration. It can be 
used also in ten per cent, lanolin ointment for mild cases, but in any case 
should not be employed long after epidermic infiltration has been reduced. 
A twenty-five per cent, ointment of resorcin is occasionally more effective than 
salicylic acid for the purposes named. Carbolic acid can be used alone, 
painted over the lupus patch as advised by Unna, or by a steel point dipped 
in the acid and inserted at numerous points after the manner of Auspitz. 
Creosote may be combined with a salicylic preparation, as in Unna's plaster, 
but I prefer creosote in dilute form — ten to forty per cent, strength of beech- 
wood creosote in olive oil or glycerine. When the lesion is located where a 
compress can be worn, saturated with the above and covered with oil silk or 
paper, it makes (in strength suited the case) a comfortable and effective dress- 



378 TREATMENT OF TUBERCULOSIS CUTIS 

ing, and is claimed by Gerenine to produce a minimum of scarring. Care 
must be exercised in the use of creosote that poisoning does not occur from 
absorption, especially if the surface treated is at all large. Bichloride of mer- 
cury in the strength of one to two grains in an ounce of distilled water, tincture 
of tolu, or in lanolin ointment is an effective germicide. In the weaker oint- 
ment it can be applied continuously. Fuchsin (one to two per cent.) and 
pyoktanin-blue have been recommended. 

A good and safe application in recent cases and in superficial forms of lupus 
is a ten per cent, solution permanganate of potash applied daily with a brush 
until the nodules are softened; then they may be wiped away with gauze and 
the application renewed less frequently. In the same class of cases painting 
the parts twice daily with equal parts of iodine and glycerine helps to promote 
absorption and can be employed in the intervals when more energetic measures 
are suspended for any cause. Pyrogallic acid is selective in its action on lupus 
tissue and has little or no effect on healthy tissue, and is usually painless in the 
strength of one to ten of simple ointment; when it is desirable to excite in- 
flammation it can be used up to thirty per cent. This may be applied spread 
on cloth and renewed twice daily. In cases indicating salicylic acid the latter 
may be combined with the former in equal parts, dissolved in collodion (one 
to ten) and painted over the lesion once daily. Besnier employs repeated appli- 
cations of a saturated solution of pyrogallic acid in ether followed by trau- 
maticine until a suppurative dermatitis is excited and all lupus points dis- 
appear. It must be borne in mind that a too free use of pyrogallic acid is 
attended with danger from absorption. 

Far inferior to the antiparasitic method of treatment, and less in vogue 
now than a few years ago, is the employment of caustics for the destruction 
of lupus. Occasionally in the nodular form caustics are serviceable, and 
probably largely because they are at the same time germicidal. Of these the 
solid nitrate of silver in crayon is one of the best. • The nodules and papules 
can be destroyed by boring into them with the pointed crayon, producing both 
a caustic and mechanical action. It has the advantages of being effective and 
exact in application, limited to the diseased tissue and in not being scar-pro- 
ducing, but the disadvantage of causing considerable pain, which persists some 
hours afterwards. Less painful, but more difficult to use, on account of its 
action extending beyond the point of contact with the tissue, is caustic potash. 
The stick can be covered all but its point and carefully used in the same way 
as the silver nitrate, keeping some vinegar or dilute acetic acid near by for use, 
to limit its action and relieve the pain if it tends to spread or the pain becomes 
severe. A combination of corrosive sublimate and carbolic acid is good, as in 
the following formula of TJnna's : 

R. Hydrarg. bichlor gr. 3. 

Acid carbolic gr. 12. 

Alcoholis 5 1. M. 

A round, small, pointed hard-wood toothpick can be dipped in this mixture 



TREATMENT OF TUBERCULOSIS CUTIS 3"^ 

and bored into every lupus papule or nodule. The pain is short. Among 
other caustics sometimes advised for lupus may be mentioned ethylate of 
sodium, carbolic acid, arsenical paste, lactic acid, chloride of zinc paste, Vienna 
paste and acid nitrate mercury. 

Mechanico-surgical methods are seldom used, but will be briefly mentioned. 

Excision needs to be carried so far beyond the diseased tissue in order to 
ensure a radical cure that it is only applicable to early lupus of small extent, 
or for single lesions on the limbs or trunk where a large cicatrix is least objec- 
tionable. Even in these cases it has little advantage over milder measures not 
usually requiring a general anassthetic. The Thiersch or Lang method of 
skin-grafting may be used to minimize the loss of surface tissue. 

Erosion or curetting is a quick way of removing accessible lupus tissue. 
It consists in scraping away the softer tuberculous growth with the dermal 
curette or sharp spoon. After a little experience the operator easily recognizes 
the sound from the lupus tissue by the greater resistance of the former, and 
avoids wounding it all that is possible with thoroughness in removing the 
lupus nodules. This method can be employed for small or large surfaces 
under a temporary anaesthetic, such as nitrous oxide gas, or local anaesthesia 
from cocaine, ice bag, ether spray, etc. Bleeding can be easily controlled by 
compression with antiseptic gauze bound firmly on for a few hours if needed, 
or in old patches where there is much scar tissue strong carbolic acid may be 
immediately swabbed over the surface as advised by Crocker, followed by the 
gauze dressing. When the bleeding has ceased, a five per cent, strength of 
boroglyceride may be smeared over the surface, and six or eight layers of 
borated gauze saturated with same laid over this, covered with oiled silk or 
rubber cloth and kept in place with bandage. This can be left undisturbed for 
several days, then renewed, and later, as healing progresses, a ten per cent, 
boric acid ointment can be substituted. Usually the wounded surface heals 
rapidly, and a thin, smooth scar results. If fresh nodules appear they can be 
scraped away with the curette or punctured with nitrate of silver stick. 

Linear scarification of lupus tissue is a much slower method of treatment 
than by scraping. It consists in making parallel incisions well through the 
diseased tissue very close together with a sharp pointed knife, or with a mul- 
tiple pointed or multiple bladed scarifier. These lines are crossed by others 
at right angles. Bleeding is checked in the same manner as after curetting. 
and may be followed by the same or similar antiseptic dressings, best adapted 
to each case, as after the latter operation. The cuts heal in a few days, and the 
operation may be repeated at intervals of eight or ten days. In rapidly extend- 
ing lupus the incisions should be carried into the apparently sound skin so 
as to include the nutrient vessels probably already affected by the advancing 
disease. It is, in fact, in the spreading type of lupus that scarification gives 
the best comparative results. This is accomplished by occlusion of the vessels 
and by stimulating fibrous growth at numerous points, thus reinforcing na- 
ture's efforts in this line of repair. It opens, however, numerous avenues into 
the sound tissues, which are liable to become freshly infected unless antiseptics 



380 TREATMENT OF TUBERCULOSIS CUTIS 

are freely applied. Iodoform, europhen or aristol can be rubbed in directly 
the bleeding from the incisions is arrested, and all subsequent dressings may 
be germicidal in nature. When the tendency of the disease to spread is sub- 
dued, new lupus nodules appearing in the affected area may be treated as 
seems best by nitrate of silver, puncture, galvanocautery, electrolysis or other 
method. 

Electrolysis may be employed to destroy isolated nodules of lupus tissue. 
The silver plate with a protective rubber ring devised by Lustgarten and 
Gartner can be used, attached to the negative pole of a battery for the larger 
nodules, and the coarse needle recommended by Jackson, in place of the silver 
plate, for the smaller lesions. The comparative painlessness of this mode 
of treatment, as well as the absence of bleeding and danger from new infection, 
speak in its favor for the purposes for which it is adapted. 

The electrocautery and thermocautery have been advocated in the treat- 
ment of^lupus. The former, chiefly by Besnier, who believes that lupus is 
often transmitted by the "bloody operations" of scraping, scarification with 
knives, excisions, etc. For this method variously shaped electrocautery knives 
and points are used to scarify or puncture the lupus growth. The pain is 
sharp, but is only felt during the operation, and if care is taken not to bring 
the needle to a white heat bleeding may be avoided. The chief difficulty is in 
limiting the destruction to the diseased tissue, the sense of touch not being 
very accurate for this purpose through the handle of a needle holder. The 
method is adapted to some cases of lupus of the mucous membranes, to sec- 
ondary papillomatous or warty growths of the skin and to the destruction of 
recurring nodules in lupus scars, but it is never likely to be a favorite pro- 
cedure in private practice. The thermocautery of Paquelin is sometimes used 
to destroy lupus tissue, but the dread of heat burning instinctive in most 
patients would restrict its emplovment if it had any special value over less 
formidable methods. 

The purposes of local treatment of lupus — removal of the cause, destruc- 
tion of abnormal growths and promoting healthy repair — are probably best 
attained in a majority of cases by the employment of photo- or radiotherapy 
combined with parasiticides. The closer the adaptation of these methods to 
the needs of each case the better will be the results obtained, not alone in the 
eradication of the disease, but with the production of the least cicatricial de- 
formity. Here, also, must be estimated the co-operative value of internal 
medication, which to the author's mind is not inconsiderable. 

The lesions of scrofuloderma call for local management according to their 
location, extent and stage of development. When latent, in the shape of 
swollen glands of moderate extent and not involving the skin, non-interference 
locally is the rule, reliance being placed on physiological and internal remedial 
treatment. If located on the face, neck or other exposed part and the skin 
shows signs of being involved it may be painted with iodine and the tincture 
carefully injected into the substance of the infiltration, in the hope that the 
germs may be destroyed and resolution effected without loss of the skin and 




TREATMENT OF TUBERCULOSIS CUTIS 881 

the consequent production of a scar. In a later stage, when the skin is fully 
involved by the subcutaneous or cutaneous scrofulous "gummata," complete 
ablation of the diseased parts under the strict methods of antiseptic surgery is 
likely to be most effective and leave the minimum of cicatricial mark behind. 
Enormously enlarged scrofulous glands not involving the skin are also prob- 
ably best treated by excision, thus saving the skin with, perhaps, slight perma- 
nent evidence of the operation. 

Open scrofulous sores may be treated on the same principles as other tuber- 
cular ulcers of the skin. Dilute peroxide of hydrogen solution or hot borated 
solution may be used frequently for the purpose of antiseptic cleanliness. 
Sometimes gauze dressings may be kept moist with one of these solutions with 
advantage for a time. Or following the regular cleansing and washing out of 
pockets and sinuses, if any, the diseased parts can be brushed over with the 
bichloiide of mercury solution (one grain to an ounce of the tincture of ben- 
zoin), dusted with europhen, aristol or nosophen, and packed or covered with 
aseptic cotton or gauze held in place with adhesive plaster or a bandage. De- 
structive agents are not often needed, but unhealthy granulations may be 
scraped away with the curette, followed by the application of strong carbolic 
acid to facilitate the healing process. Sinuses may require to be laid open for 
the same purpose. 

In the generalized form of acne scrofulosus daily or semi-daily bathing 
with boric acid or sublimate soap is the only local treatment needed. If the 
scrofulous cachexia is well marked or the patient anaemic, inunctions of cod 
liver oil are of service. The few lesions of the more localized forms may be 
painted occasionally with iodized collodion, a solution of corrosive sublimate or 
with an ethereal solution of pyrogallic acid. 

II. Internal Treatment. — The prophylactic value of physiological treat- 
ment has been already mentioned. It is of equal benefit in the curative 
treatment of tuberculosis of the skin. All available methods of hygiene may 
be utilized to improve or fortify tissue and bodily vigor. Change of climate, 
or even from the habitual scene of dwelling, is often beneficial. A diet may be 
selected best adapted to a given case. Easily digested fat is almost always an 
aid in the process of nutrition, but choice of food must sometimes be influenced 
by the state or powers of digestion as by the nature of the food itself. No 
strict dietary is advisable for the tuberculous, because the requirements of no 
two patients are the same, and like many matters of hygiene must be adapted 
to the limitations of each one. 

Among drugs there are no specifics for tuberculosis of the skin, but there 
may be in any case a specific for the individual in the group of tissue remedies. 
Here individualization may be carried through symptoms into pathology 
sometimes with advantage in selecting a remedy. Tuberculin employed after 
the manner proposed by Koch has shrunk nearly out of sight as a curative 
remedy for tuberculosis. But its power of aggravating the tuberculous process 
is well established, and hence to those who believe in the efficacy of the smallest 
curative doses it becomes a remedy in an attenuation high enough to produce 



382 LICHEN SCROFULOSUS 

only the faintest trace of aggravation. In slow but persistent types of lupus 
I have much confidence in the action of tuberculinum. The difficulty has been 
to find the right attenuation. The sixth decimal is probably the nearest ap- 
proximate strength for all cases, administered not oftener than twice daily 
and suspended altogether every few days when an effect is noticeable. For 
other drug remedies see indication for Arsen., A. iod., Aurum mur., Baryta 
car})., B. iod., Cal. phos., C. sulph., Fluor, acid., Graph., Hydrocot., Kali 
bichrom., K. brom., K. mur., Kreso., Lyco., Mez., Nat. mur., Phos., Phyto., 
Psor., Sil., Staph., Stilling., Thuja. 



LICHEN SCROFULOSUS 

(Lichen circumscriptus; Lichen scrofulosorum ; Perifolliculitis tuberculosa; 
'~^ Tuberculosis cutis lichenoides, etc.) 

Definition. — The characteristic eruption of lichen scrofulosus occurs 
in very small, pale or yellowish-red papules, usually arranged in circles or 
groups, and chiefly in persons showing other signs of scrofula. 

Symptoms. — The eruption is often accidentally discovered, not enough 
discomfort having arisen from it to cause the patient to complain or seek 
advice. Eecent papules are red : later they become yellowish or pale, sometimes 
fading to the normal color of the skin, but they do not change their conical 
form until they resolve, leaving a moderate stain behind. Occasionally a 
minute scale forms at the apex of the papule. 

The location of the eruption is generally upon the front of the chest, abdo- 
men, or sides of the trunk. In children the eruption is sometimes found on the 
extremities. The course is chronic, with perhaps little change in the lesions 
lor months, or fresh groups appear upon other portions of the skin as the earlier 
patches disappear. In cachectic persons, pustules may form sometimes after 
a sebaceous plug has accumulated, and on the face or limbs pustular acne may 
coexist (see acne cachecticorium). Barely pustular eczema about the genitals 
or seborrhcea of the scalp or other parts of the surface may be present at the 
same time. The disease occurs most commonty in youth and always before 
middle life. Local sensations are slight or absent, and no excoriations are seen 
as an effect of scratching. 

Etiology and Pathology. — The scrofulous diathesis is the main, perhaps 
the only cause. This is obvious in most cases from the swollen cervical, sub- 
maxillary, axillary or other lymphatic glands and tonsils; scrofulous joints, 
caries or other bone diseases are not infrequent, and there is often a family 
history of phthisis. The pathological cause, according to Kaposi, is a "cell 
infiltration and exudation in and around the hair follicles and their sebaceous 
glands (folliculitis), as well as the papilla? immediately adjoining the opening 
of the follicles." The central scale is formed by accumulated epidermis at 
the follicular opening. If a pustule forms it has the same seat, the follicle may 



ERYTHEMA INDURATUM 

be destroyed and a scar result. The tubercle bacillus has been found in the 
lesions by a number of observers. 

Diagnosis. — The pale or yellowish-red, small size papules arranged in 
circles or groups upon the trunk, together with other evidences of struma, are 
sufficiently characteristic to identify the disease from all others. The papules 
of eczema do not have the same location ; they are redder, may become vesicular 
and are attended with more marked pruritus. Both the lesions of punctate 
psoriasis and lichen ruber undergo changes and become more scaly, unlike 
lichen scrofulosum. The miliary syphilide (lichen syphiliticus) is rarely 
limited to the trunk, and other evidences of syphilis can usually be found. 
Keratosis pilaris is usually located on the extensor and outer surfaces of the 
extremities, and is not commonly associated with signs of scrofula. 

Prognosis. — This is always favorable under judicious treatment. The 
cachectic type of the disease may be obstinate until the underlying scrofulous 
taint is overcome. 

Treatment. — This is essentially the treatment of scrofula, by physiological 
methods, to improve nutrition and the hygiene of daily life, fresh air, sunlight, 
etc. Locally inunction with some nutrient fat is of much service, such as cod 
liver oil, fresh butter or olive oil. Internal remedies are to be selected which 
cover the whole pathogenesis. See Arsen. iod., Baryta carb., B. iod., B. mur., 
Cal. carb., Kali carb., K. iod., Mez., Staph. 



ERYTHEMA INDURATUM 

(Erytheme indure des scrofuleux, Bazin.) 

This is a rarer form of exudative erythema, which Bazin claimed was mis- 
taken for erythema nodosum. It occurs in single, or less often multiple swell- 
ings, superficial or deep-seated in the skin, one-fourth of an inch or more in 
width, but which may coalesce to form large areas of brawny induration. The 
deeper seated may cause at first little or no change in the color of the skin and 
can be felt better than seen ; over the superficial lesion the skin is bright red in 
the early stage, later assuming a livid hue, as may also the skin over the deeper 
indxiration. The infiltration slowly resolves as a rule, but may go on to 
sloughing and the formation of an ulcer. The lesions are nearly always sit- 
uated on the outer or posterior aspect of the leg below the knee. This disease 
is usually met with in public practice and is rare. It has been observed in 
connection with the tuberculides and in persons having general tuberculosis. 

Etiology. — Girls from fourteen to twenty years of age are most often 
affected and usually in the winter. Shop-girls, scrub-women and others who 
stand for long periods at a time or whose circulation is weak, are more exposed. 
The tubercle bacillus seems to play the efficient causal role. 

Pathologically, the tuberculous nature has been demonstrated, although 
inoculation experiments have usually been negative. 

Diagnosis. — It may be necessary to differentiate the gummatous syphilide. 




384 SYPHILIS 

which is benefited by specific treatment and which is asymmetrical in location. 
Erythema nodosum is acute, does not ulcerate or form scars and has no asso- 
ciated tubercular features. 

Treatment. — This is usually that of any tubercular condition; physiolog- 
ical living being the aim. If ulcerations take place, antiseptic dressings will 
be needed. For internal treatment see indications for Aurum mur., Bell., 
Kali. brom. 

SYPHILIS 

(Morons gallicus; Lues venera; Pox, etc.) 

Definition. — A general infectious disease, transmitted by direct or 
mediate contact of infected secretions and by heredity, chronic in its 
course^-and during which it may involve any one or more of the tissues 
and organs of the body. 

The consideration of the disease here has chiefly to do with its cutaneous 
manifestations known as syphilodermata or syphilides. These are ordinarily 
supposed to begin at the culmination of the so-called stage of secondary incu- 
bation or as secondary manifestations of syphilis, but inasmuch as the earliest 
lesion of the disease very often begins in the skin no proper conception of 
the process can be grasped without including in its study the primary mani- 
festations. Indeed, a better understanding of syphilis may be had by dropping 
altogether the artificial division of Eicord into primary, secondary and tertiary 
periods, and rather viewing it as a progressive infective process, influenced 
greatly in its course by the character of the soil in which the virus is acci- 
dentally implanted and by the treatment employed, but characterized by short 
or long intervals of insidious progression (not incubation) along the vascular 
channels, and culminating with a degree of systemic saturation which gives 
rise to the so-called "explosion" in syphilitic fever, pains, weakness, depression 
and perhaps a sudden efflorescence on the skin. More often these culminating 
manifestations develop slowly without necessary proportion or sameness in 
any two persons. 

In no case can it be said from indications in the early stages that a case 
of syphilis will absolutely pursue on the one hand a benign or on the other a 
malignant course. Between the mild and transitory type of the disease and the 
malignant, persistent and destructive form all grades may occur. But in gen- 
eral it may be said that in proportion as the victim of syphilitic infection is 
well and vigorous, with a system not undermined by hereditary taint, pre- 
vious disease, dissipation, in the same proportion is the disease likely to be 
mild and superficial, and as the majority of the people possess a fair degree 
of health and vigor so the majority of cases of syphilis pursue a benign though 
often persistent course. 

The period of incubation of syphilis or the interval between the exposure 
to the contagion and the development of the primary lesion has been given 



SYPHILIS 385 

at the extremes of one day to about three months; in nearly all it falls be- 
tween the tenth to the fortieth day, averaging about twenty-one days. 

The initial sore or chancre varies in appearance somewhat according to 
location and exposure to irritations of various kinds. At the more common 
genital sites on the penis or labium the earliest perceptible change may be a 
minute red spot which in eight or ten days grows into a well-defined nodule, 
becoming gradually hard during the following two or three weeks. Superficial 
erosion of the surface only may take place, or an ulcer may form bounded by 
an indurated but non-elevated border, constituting the "Hunterian chancre." 
Sometimes only a desquamating papule appears (or with exceptional rarity a 
small dusky spot), which without ulceration disappears rapidly by reabsorp- 
tion, perhaps without the patient's having been conscious of its presence. 
These small and innocent looking lesions are easily overlooked or lightly esti- 
mated even by physicians. Occasionally chancres simulate closely herpes 
progenitalis, or they may become ecthymatous from irritation, pus production 
and crusting. The induration may be spread out, forming a parchment-like 
lesion, or the new growth may be distributed in ring shape (annular chancre), 
and sometimes there occurs an excessive cell infiltration forming an elevated 
lesion, which may rarely become covered in the centre by a greenish mem- 
brane, the so-called "diphtheritic" chancre. It is well to remember that the 
primary sore may vary widely in size and appearance, and may coexist with 
or follow herpes, chancroids or other mixed infections, occasionally resulting 
in considerable destruction of tissue. Usually the primary sore has a tendency 
to heal slowly, rarely lasting less than eight weeks when unmodified by treat- 
ment, and occasionally its course is protracted for a year or more. 

About ninety per cent, of all cases of primary syphilis begin on or about 
the genital organs, and in the male are situated on the frenum, inner surface 
or margin of the prepuce, the glans, at the orifice or within the orifice of the 
meatus, on the skin of the penis and occasionally on the scrotum. In the 
female they are most common on the inner aspect of the labia majora, the 
nympha, less often on the clitoris, os uteri and rarely in the vagina. In about 
ten per cent, of all cases the initial sores are extra-genital and very frequently 
are accidentally or innocently acquired (syphilis insontium). The more usual 
location of extra-genital chancres are the lips, mouth and throat, breast and 
nipple, fingers and hand, eyelids and conjunctiva, chin, cheeks, nose, arms, 
and rarely in almost any region of the body. Besides, a large number of 
chancres have been ascribed to infection at the time or subsequently to the 
slight operations of vaccination, cupping and bleeding, circumcision and tat- 
tooing. 

The well-defined induration characterizing chancre of the genitals five 
or six weeks after infection is not always apparent in extra-genital sores, owing 
largely to anatomical differences; on the lip, for instance, there is seldom 
any marked induration. Neither is there much, if any, induration in chancres 
of the nail bed, while a primary sore in the cheek may be quite obscured by 
the attendant oedema, and sometimes reach an enormous size and simulate 
malignant disease. 



386 SYPHILIDES 

Syphilitic chancre is usually single, but it may be multiple according to 
the number of points inoculated at the time of contagion or during incubation. 
As a rule, when the sore has developed it affords protection against further 
infection, though the immunity is not always certain or permanent. Con- 
secutive with the cellular infiltration of the chancre the nearest lymphatic 
glands become swollen and hard, and other connecting or distant glands may 
become affected, showing the distribution of the poison from the primary sore 
going on throughout the system. The enlarged glands show no sign of in- 
flammation and are rarely tender. At the acme of this insidious progression 
of the disease into all parts of the body various resulting disturbances may 
arise early or late. These may be enumerated as syphilitic fever, which rarely 
exceeds 102, but may reach 104 or 105 at times at the nightly exacerbation; 
disorders of the nervous system, such as neuralgia, especially of the fifth nerve, 
derangements of sensation and reflexes, nocturnal headache, insomnia and 
exceptionally mental derangements, rheumatoid pains at night, cold feet and 
hands; anaemia, cachexia and asthenia, sometimes amounting to a typhoidal 
condition accompanied with splenic enlargement; jaundice; albuminuria and 
sometimes temporary nephritis. These and other less common indications of 
systemic infection vary in different persons to a remarkable degree, occasionally 
are altogether absent, and the cutaneous eruptions may be the only signs of 
syphilis. 

SYPHILIDES 

The cutaneous manifestations of constitutional syphilis may appear at 
any period in its course, and while no strict chronological order is always ob- 
served, each lesion has its favorite period of occurrence. 

The pathological basis for the syphilodermata rests on two processes in the 
skin — hypercemia and cell-infiltration; in a general way it may be said that 
the first characterizes the earlier and more superficial lesions, and the cellular 
the later and deeper lesions in proportion to the duration of the syphilis. 
These two processes alone or together with various subsequently induced 
changes give origin to numerous and varied forms of eruption; so much so 
that some one has described syphilis as an "imitator of other diseases." The 
resemblance to other eruptive diseases is natural, inasmuch as the same ana- 
tomical parts are involved in all by an i-nfla. Tmri a.tnry process, but which in 
the case of syphilis (and some others) is dominated by a specific cause. The 
imitation therefore is hardly more than objective and is usually overbalanced 
by distinct differences. These characteristic differences, each alone of little 
diagnostic value, together form a significant clinical group, and may be studied 
in general contrast with the simple eruptions of other diseases. 

The course of cutaneous syphilis is nearly always slow, both in development 
and decline, and is seldom attended with the inflammatory features of simple 
eruptions. Occasionally an active erythematous or papular eruption of the 
early period may be attended with pronounced systemic reaction, fever, and 



BYPHILIDES 887 

closely simulate an exanthem, but the apparent muteness of the syphilide 
very soon passes into a subacute course. Sometimes local irritations produce 
associated congestion and inflammation of the later syphilides. Another fea- 
ture is the tendency to evolution in crops, often with a variation in the eruptive 
elements, papular and other lesions frequently appearing before the preceding 
lesions have reached their full development. 

This ■polymorphism of the early syphilides occurs in the majority of cases, 
and maciiles, papules, pustules and scaly lesions may coexist in all stages 
of evolution and decline, or successively exhibit their varied phases in transi- 
tion of one form into another. Multiple forms of eruption never occur to 
the same extent in non-specific diseases. 

The order of evolution of the syphilides while not absolute is sufficiently 
so to be characteristic. With few exceptions the skin is involved from without 
inwards — from the more superficial to the deeper parts. At a variable inter- 
val, averaging about six weeks after the development of the primary sore, 
the so-called secondary eruptions begin to appear as a result of a contamina- 
tion of the blood with the special virus. Hence, like the eruptive fevers, they 
are usually symmetrically if not generally distributed. The most super- 
ficial, or the hyperaemic macules, are the first to occur, followed by the deeper 
but still superficial papules ; and when the intensity of the process is sufficient, 
these may be accompanied or succeeded by pustules, etc. Thus the kind of 
lesions present are somewhat indicative of the age of the disease. 

The papule is the most typical of the secondary lesions, and occurs in varied 
forms, to be described later. The eruptions of this period of constitutional 
syphilis, which is supposed to last about two years, are seldom constant. They 
tend to disappear spontaneously at variable intervals, and to recur again and 
again until the virulence of the syphilitic process is worn out or controlled by 
treatment. With the termination of this limited stage of systemic syphilis 
may end all manifestations of the disease. In a minor per cent, of cases the 
poison may leave behind definite tendencies to morbid cell growths, which may 
become active at once or remain latent for months or years, and then under 
some favoring condition of nutrition suddenly exhibit vitality and find expres- 
sion in some form of non-virulent or tertiary syphilis. 

The tubercle is the typical lesion of tertiary syphilis of the skin, as the 
papule is of the earlier stage. The tertiary syphilides in comparison with 
the so-called secondary lesions are characterized as follows : They are much 
less constant in occurrence; when they do appear they are without order of 
succession; they are asymmetrical, localized, deep-seated, tend to persist and 
spread, cause local destruction of the tissue and leave permanent scars; they 
do not yield to mercury in full doses, but may be often arrested with iodide of 
potash. Lastly, though they may recur during the patient's life they are at 
no time contagious or inoculable. 

It must be remembered that the foregoing applies more or less accurately 
to the typical evolution of the syphilides, which may vary greatly in intensity, 
in the number and extent of the lesions and their several duration and succes- 



388 SYPHILIDES 

sion. Very rarely there may be an almost complete reversal of the law of 
syphilitic evolution, and deeper lesions common to the tertiary period may 
antedate the superficial eruptions of the secondary period. This has been 
termed retrogressive syphilis. In another irregular type the usually late and 
deeper tubercles, gummata, etc., develop before the early and superficial mac- 
ules, papules and pustules subside, or follow closely their decline and pursue 
an acute non-destructive course defined as rapid benign syphilis. Less often 
the rapid, violent and extensive involvement of the deeper tissues assumes 
a malignant destructive course known as precocious malignant syphilis. 

Lesser irregularities in the evolution of the syphilides, such as the pre- 
dominance or persistence of one kind of lesion, the moderate occurrence of 
the early lesions in the late or tertiary period, or lesions of the latter within 
the limits of the secondary stage, are not so very uncommon. 

In location the syphilitic eruptions of the secondary stage resemble the 
exanthemata in being more or less generalized, but do not show much tendency 
to imitate simple eruptions in localization. In fact, in certain areas such as 
the sternal, the supra- and infra-clavicular regions, and the dorsal surfaces 
of the wrists, hands and feet, where inflammatory eruptions are often seen, 
the syphilides seldom appear. The form of the eruption apparently deter- 
mines the location to a great extent. The macular syphilide is commonly 
found on the chest, trunk and flexor surfaces, but rarely on the face and neck, 
where the papular form is often seen. The latter also shows a predilection 
for the forehead, at the margin of the hairy scalp, the limbs and trunk. The 
pustular syphilide is prone to appear on the hairy parts of the scalp, face and 
other regions well supplied with sebaceous glands and hair follicles. Moist 
papules or mucous patches occur almost exclusively on the warm or moist 
region of the body. Tubercular and other late syphilides may develop almost 
anywhere, though the erythematous and rupial forms, like non-specific lesions 
of the same type, show a preference for the legs. 

• The tendency of some syphilides, especially the small papular and relapsing 
erythematous, to become grouped in curved lines, circles or segments of circles 
is sometimes quite marked, and is probably due to the anatomical arrange- 
ment of the capillaries of the particular areas. Circinate lesions also occur 
from the involution beginning in the centre of large papules or tubercles, 
leaving the periphery to disappear later or advance further in a regular or 
irregular way as it recedes centrally. Herein is exhibited a pathological law 
of syphilitic infiltration of the skin, in that it increases and undergoes involu- 
tion both in a centrifugal direction. Even in the destructive forms of retro- 
gression this holds true in some degree, and serpiginous, horseshoe and eres- 
centic shapes of ulcerative lesions are quite characteristic. 

The color and pigmentation of the syphilides are not so characteristic as 
is generally supposed, like changes occurring with or after some other diseases. 
At first the color is often a pinkish-red, only slightly more subdued than simple 
eruptions, and disappears on pressure. Later it fades to a brownish-red, yellow- 
ish-brown, or coppery tint, due to the deposit of pigment matter from the 



SYPHILIDES 889 

blood and to subsequent changes which give a certain permanency to the stain. 
On the lower limbs and in other dependent portions the color may be early of a 
bluish or dark red, from combined blood stasis and pigment staining. Both 
the hypersemic tint and pigment coloration are modified by the normal texture 
and complexion of the skin, and, as has been shown, by the age of the eruption. 

Karely pigmentation occurs independently of other lesions and is then 
known as the pigmentary syphilide. 

The scales of syphilis are characterized as thin, superficial, scant, dull while 
or yellowish in color and non-adherent compared with the same product of like 
simple eruptions. 

The crusts of syphilitic pustules and ulcers are quite distinctive. They are 
grayish, brownish or greenish-black in color, rest upon indurated base and are 
easily detached; they are thicker than the crusts of simple lesions and are built 
up in layers from the secretions formed beneath. If of large size (ecthymatous 
or rupial) they may seem to almost float upon a base of liquid pus; and the 
conical, laminated brownish-black crusts of the rupia type, which may slowly 
attain a large size, are pathognomonic. The brownish-black, rough, dirty, 
oyster-shell-like crusts of late syphilitic ulcers are also characteristic. 

The ulcers of syphilis may be round, oval, crescentic or horseshoe in 
shape, due to both the enlargement and the subsequent healing taking place 
more or less regularly from within outwardly. Hence, the margins are gen- 
erally regular and their edges perpendicular. The floors may be grayish or 
present a membranous appearance, bathed with a sanious pus and the lesion 
bordered by a reddish areola. 

The cicatrices of syphilis are often diagnostic. They are distinctly round 
or oval in shape; at first reddish-brown in color, they gradually fade from the 
centre to the periphery until when mature there is left a white, smooth, shining, 
more or less depressed pliable surface, bounded by a narrow areola of brown 
pigmentation, which is usually very persistent. Xear the joints syphilitic 
scars may be traversed by fibrous bands; more often they are smooth or only 
minutely perforated at the follicular opening. 

. A common negative characteristic of the s}-philides is the absence of pain or 
itching during the entire course. If the process is unusually acute or the 
lesions are subject to external irritation they may be sensitive or painful, and 
when situated in warm or moist regions of the skin or occurring in the eczema- 
tous they may be attended with sensations of itching. Frequently patients are 
unaware of the existence of the eruption until it is accidentally seen. 

The action of mercury in the system in causing the disappearance of the 
syphilodermata of the secondary group is characteristic. There are occasion- 
ally exceptions, but its influence over the infiltrating lesions of this period is 
remarkable and may be of diagnostic value. 

The course of the syphilides may be hastened, interrupted or modified by 
some intercurrent diseases, which, however, do not affect the syphilitic diathesis 
sufficiently to often prevent ultimate relapses. Such effects have been noted 
from the occurrence of acute febrile attacks of various origin, scabies, miliaria 



390 



SYPHILIDE3 



rubra, furuncles, etc. On the other hand, syphilis beginning during the 
course of non-specific eruptions may be aggravated and prolonged by them, 
especially as regards eczema and seborrhcea. Occurring in scrofulous and 
lymphatic individuals the syphilides are not only liable to be more severe, but 
to partake somewhat of the character of the earlier diathetic affection. 

Many and varied influences may act to modify or aggravate the behavior 
of the syphilides in one or more directions; among them idiosyncrasy, age, 
climate, general and personal hygiene, alcoholism and local irritations and 
infections. These are not peculiar to syphilis, but it is these and other acci- 
dental and incidental agencies and the reactions they call into play in the 
organism, rather than the elementary lesions, which account for the multiple 
and confusing manifestations of the disease. They give individuality to each 
case and afford a scientific basis for remedial therapeutics inclusive of specific 
remedies for a specific virus. 

Various classifications of the syphilides have been proposed. The division 
of Leloir into two groups, resolutive (secondary and non-destructive) and 
non-resolutive (tertiary and destructive), has the advantage of being simple and 
in harmony with the prevailing tendency to gross pathological change; but it 
fails to give place to the usual order of occurrence of the different lesions or of 
the kind of lesions as commonly considered in the study of other eruptive 
diseases. Modifications of the plan of Cazenave based on the form and path- 
ology of the lesions and grouped in the order of their occurrence in typical cases 
have stood the test of general usage long enough to establish its value for prac- 
tical study. In this the erythematous, papular, pustular and tubercular rep- 
resent the elementary types of eruption, while their blending together and 
changes from secondary processes are designated, as in simple affections, by 
compound terms, such as papulo-vesicular, ecthymaform, etc. Bare accidents 
of pigmentation or hemorrhage make a fifth division. This arrangement of 
lesions may be seen at a glance in the following table : 



I. Erythematous form. 



\ Macular, 

I Maculo-papular. 



Due to hyperaemia 
with slight infiltra- 
tion. 



II. Papular form. 



Miliary papular, 
Lenticular papular, 
Papulo-squamous , 
Moist papular. 



Due to circumscribed 
follicular or papil- 
lary infiltration. 



III. Pustular form. 

IV. Tubercular form. 
V. Pigmentary form. 



Varicellaform and Variolaform, 

Acneform, 

Impetigoform, 

Ecthymaform, 

Rupial, 

Pemphigoid. 

j Tubercular, 
( Gummatous. 

\ Pigmentary syphilide, 
} Purpuric syphilide. 



Due to infiltration 
with superficial sup- 
puration or ulcera- 
tion. 



Due to deep infiltra- 
tion with a tendency 
to ulceration. 

Due to extravasation 
of blood constitu- 
tion. 



SYPHILIDES 891 

I. The erythematous syphilides. — (Syphilitic roseola; exanthematoua 
syphilide; erythema syphiliticum; macular syphilide, etc.) 

This is usually the earliest syphilitic eruption; it commonly occurs in the 
seventh week after the primary sore and is usually preceded by moderate 
syphilitic fever. Sometimes it appears earlier, but rarely later, though relapses 
are not infrequent. It may be distinctly macular or less often maculo-papular 
in form. 

The macular syphilides occur in round or oval spots with irregular or ill- 
defined margins and averaging about one-third of an inch in diameter. At first 
their color is often a bright pink or rose-red and disappears on pressure, but in 
a few days to four weeks they assume a bluish, grayish-brown or coppery color, 
which is only partly or not at all changed by pressure. Occasionally they may 
disappear without the latter change in tint, and sometimes the color is so faint 
as to be hardly noticeable unless seen obliquely. Single patches develop in 
about two days, and the whole eruption may appear in seven to ten days. Ex- 
ceptionally from the intensity of the poisoning or some exciting cause the 
efflorescence may invade the whole surface in one day. 

Usually the eruption occurs earliest and most abundantly over the chest 
and abdomen, next upon the upper portion of the extremities, neck and back. 
Occasionally the eruption is widely or generally distributed, though it seldom 
invades the face or the dorsal surface of the hands and feet. In rare instances 
it may begin upon the face ; quite commonly it is confined to the trunk. The 
lesions may be few or many; they show, as a rule, no tendency to become 
elevated, to coalesce, to form circles or to become scaly. The eruption seldom 
disappears before the end of a week, and rarely lasts more than a month, leaving 
behind a brownish-gray stain. Eelapses may occur during the first year, and 
small circinate forms may appear in the second or third year of syphilis or even 
later, and prove rebellious to treatment. 

This syphilide probably occurs in nearly every case; but slight constitu- 
tional disturbances, absence of local sensations, moderate coloration of the 
skin and limitation to the covered portions, or in some cases the presence of 
other and more pronounced eruptions, may cause it to be frequently overlooked. 

The maculo-papular syphilide occurs from a more intense hyperemia than 
is present in the macular form. In comparison with the latter the spots are a 
deeper red, slightly elevated, change to darker or a purplish tint, and have 
developed over them without definite order small papular formations. These 
may be confined to the hair follicles and consist of hyperasmic punctae, or of 
slight cell growths at the follicular opening (granular roseola), or again of 
very moderate papillary cell increase, sometimes called roseola urticata. Very 
often the papular lesions have a tendency to form circles or parts of circles. 

The maculo-papular syphilide is apt to be preceded by more constitutional 
disturbance than the distinctly macular and to be more prompt and rapid in 
its invasion, more persistent and chronic in its course, and often exhibits more 
or less desquamation throughout. 

Occasionally the erythematous syphilide may exist with and follow the 



392 SYPHILIDES 

evolution of seborrheic dermatitis in its development, especially when situated 
on neck, face and thorax. The initial lesion as well as the secondary eruptions 
and symptoms of the disease may also coexist with this syphilide in some parts 
of its course. Syphilitic alopecia and more rarely iritis may occur. 

Diagnosis. — Chief reliance may be placed on the presence of an initial 
lesion or induration left at the point of inoculation, on the enlarged glands and 
constitutional symptoms, together with the form of hyperaemic patches, pigment 
stains and the exemption of exposed surfaces. 

In the early stage it might be mistaken for the rash of measles, scarlet 
fever or the erythema from the ingestion of drugs. The more frequent occur- 
rence of the eruptive fevers in children and the syphilides in adults, the dif- 
ferent onset and absence of the catarrhal symptoms of rubeola, or the throat 
symptoms of scarlatina, strawberry tongue, etc., will serve to exclude the two 
last diseases. 

Drulf-erythemas from copaiba, cubebs, mercury, the coal tar products, etc., 
soon disappear after the causal drug is suspended, leaving no trace, as a rule. 
In such cases a history of the use of the drug is usually obtainable, and the 
case will, in the absence of syphilis, show none of the concomitant signs of that 
disease, such as the initial sore, infiltrated glands and some of the group of con- 
stitutional phenomena. 

Tinea circinata when of a pinkish-red color may simulate the erythematous 
syphilide. The single or comparatively few lesions, lack of symmetry, greater 
scaliness, usual occurrence in children, and in doubtful cases an examination 
of the scales for the ringworm fungus will always distinguish the former from 
the syphilide. 

Tinea versicolor can never give much trouble in a differentiation from the 
macular syphilide, although the color and location may be very similar. The 
ease with which the pigmentation of tinea versicolor can be rubbed or scraped 
away while the syphilitic patch would remain unaffected or become more hyper- 
semie from the friction, and the great abundance of the microsporon furfur in 
the scrapings from the tinea versicolor would never leave any room for doubt 
as to the presence of the latter. Its usual history of long duration and an 
absence of any evidence of syphilis would be further distinguishing points. 

Pityriasis rosea has a like distribution and duration as the macular svphilide, 
but its lesions are larger, more scaly and there is an absence of staining and the 
concomitant symptoms of syphilis. 

II. The papular syphilides. — The circumscribed infiltration of the super- 
ficial structures of the skin, or the papule, is the most important of the secondary 
accidents of syphilis, and occurs in two primary forms — the miliary and the 
lenticular. 

The papular may be the earliest manifestation of cutaneous syphilis, either 
alone or combined with the erythematous lesions ; or they may follow the latter 
and constitute the chief recurring eruption of the whole secondary period. 
They may even persist into the tertiary stage and by intermediate papulo- 
tubercles merge into the tubercular syphilide. Commonly, however, they do 



SYPHILIDES 898 

not appear before the fourth month or recur after the end of the second year. 
They may be more or less disseminated in the earlier stage, but the later the 
appearance, or with each successive recurrence, they tend to develop in circular 
groups and show a more marked predilection for certain regions. The region 
and structure of the skin determine in part their subsequent behavior. Thus, 
on the scalp they tend to assume a crusted form; on the general surface to 
become scaly; at the angles or folds of the skin, corners of the mouth, be- 
tween the toes and fingers, etc., to the formation of painful cracks; on the 
palms and soles they tend to persist and simulate psoriasis; on opposing 
surfaces, especially about the genital and anal regions, they are apt to be- 
come moist and extensive. 

Any or all the variations of the papule may coexist at the same time, but 
their size, form, mode of evolution, etc., are sufficiently distinct to be classified 
in four subdivisions. These are the miliary papule, the lenticular papule, the 
squamous papule and the moist papule. 

The miliary papular sypKilide (syphilitic lichen) is the least common 
of all the papular forms of eruption and occurs chiefly in females. The 
lesions consist of an infiltration of the follicular structures of the skin (folli- 
cular syphilide), and vary in size from a pin's head up to double or treble 
that size. The smaller variety is quite rare, and Crocker says his cases were 
all females. The lesions • consist of minute, conical elevations, of a bright 
red color; at first they soon fade to a fawn or coppery hue, and on involution 
of the papule leave a bluish or brownish-red stain. This eruption, which 
may occur in the first or second year of the disease, is often generally distrib- 
uted in groups of four or five up to forty lesions. These are usually most 
abundant about the face, neck, sternal region and back of the shoulders. The 
eruption often appears rapidly, is persistent and new lesions may continue 
to appear for several months. Sometimes a minute vesicle forms at the apex 
of the papule (miliary papulo-vesicular syphilide), which dries in a few 
days, leaving a superficial scale. In other cases the process may be intense 
enough to form a minute pustule (miliary papulo-pustular syphilide). which 
results in the formation of a minute crust. The larger miliary syphilide 
is not so infrequent as the small variety. It has the same seat on the follicles 
and is most commonly seen on the back, extensor surfaces of the extremities, 
neck and anterior part of the chest, but it may be more generally distributed. 
The lesions are larger, rounder, fewer and occur in less regular groups than in 
the first form. Frequently the epidermis over the body of the lesions exfoliates, 
leaving a fringe of whitish scales around the papules. They seldom appear 
or reappear after the first year of the disease, though it is to be borne in mind 
that large papules may coexist with smaller lesions without special order or 
arrangement in location or time. 

Diagnosis. — The only disease likely to be confounded with the miliary 
syphilides is lichen scrofulosum. The latter occurs in childhood, rarely after 
puberty and never after thirty, and though situated in the follicles and 
grouped like the syphilide, the eruption is nearly always confined to the trunk. 



394 SYPHILIDES 

■while the syphilide is unusual in childhood and has a wider distribution. 
Moreover, lichen scrofulosus is almost invariably associated with other evi- 
dences of scrofula, and the miliary papular syphilide with other signs or a 
history of sj'philitie infection. 

The lenticular papular syphilide (large papular syphilide) is the most 
common, extensive and persistent eruption of the secondary period. It may 
occur early before the macular form has disappeared or follow it closely, and 
in successive crops continue to recur during the first two years. Occasionally 
it is one of the relapsing manifestations of late syphilis. The lesions are at 
first small and gradually increase until they attain a sixth to a half inch 
in diameter; they are roundish, flatly convex, well defined and only slightly 
elevated. As they develop the color changes from a bright red to a shiny 
coppery hue, the epidermic covering desquamates, leaving the same fringe- 
like color about the base mentioned as occurring with the large miliary lesions. 
With succeeding desquamations the papules become flatter and gradually dis- 
appear, leaving at their sites grayish or brownish and persistent stains. In 
the early stage the lesions are apt to be numerous and widely distributed, 
but are not often grouped, though they may be closely situated about the 
genitals, forehead and mouth. Occasionally when numerous or near together 
they may coalesce to form broad patches. They show a predilection for the 
forehead (constituting along the margin of the hair a form of the corona 
veneris), lower part of the face, back of the neck and shoulders, the flexor 
aspects of the elbows and knees, the genito-anal regions and the palms. Fresh 
crops may appear before the preceding lesions have resolved, and sometimes 
papules may be seen in all stages of evolution and involution. With each suc- 
cessive crop the lesions diminish in number and increase in size until the 
latter outbreaks may consist of only a few grouped papules within limited 
regions. 

Diagnosis. — This characteristic syphilide is easily recognized. Its form, 
mode of development, color, etc., are practically diagnostic, and the frequent 
association of other signs of syphilis— mucous patches, glandular infiltration, 
alopecia and the absence of subjective sensations — will remove all doubts as 
Lo its nature. Some of the larger lesions may resemble the tubercles of leprosy, 
but the different origin, development, concomitants and behavior under treat- 
ment would serve to identify the syphilide, even with the possible association 
of the two affections. 

The papulosquamous syphilides (nummular sj-philide; syphilitic psor- 
iasis, etc.) are really common modifications of the large papular form, due 
to various influences probably largely resident in the skin affected. What- 
ever the cause may be, there occurs, consecutively with the syphilitic infil- 
tration of the derma, an increase in the superficial layers, with a more or less 
marked proliferation of the epithelial elements, and resulting in the accumu- 
lation on the surface of the papules of dry, dirty, grayish, often thick and 
friable scales. Exceptionally the scales may be horny, dense and adherent. 
Any papular syphilide may exhibit a scaly formation from the first up to 




Fig. 110— SECONDARY SYPHILIDE 

EARLY LENTICULAR PAPULAR VARIETY 

Patient is a woman of about thirty-five, who developed a primary sore four months 
ago, a macular efflorescence over the trunk eight weeks later and the present eruption about 
two weeks ago. The lesions are slightly convex, a coppery-red color, and are generalized, 
though most numerous on the face and extremities. 




Fig. 111.— SECONDARY SYPHILIDE 

LATE LENTICULAR, PAPULAE AND PAPULO-SQUAMOUS VARIETY OF THE BACK 

Patient is a young man who gives a history of primary infection twenty months 
ago and of outbreaks of dry eruptions at times for one year and a half. The present 
lesions have appeared in crops for four months, chiefly on the face, back and chest. 
They exist in all stages of evolution; the last to appear are round or oval papules free 
from scales, while the older vary in some degree of scaliness. 




SYPHILIDES 895 

the acme of development, or only in the stage of decline, but it is only when 
the scaliness is comparatively abundant and persistent that it gives clinical 
character to the eruption. The resemblance of some of these lesions to 
psoriasis led to the use of the term syphilitic psoriasis, though the scales are 
rarely pearly or silvery white as in the nonspecific disease. The mildest type 
of the papulo-squamous syphilide is rare and presents only a furfuracemi- 
desquamation of rounded, slightly raised patches here and there, known some- 
times as syphilitic pityriasis. 

The most common type is observed in the larger and deeper papules of 
the latter part of the first year, or less often in the second year, of the secondary 
syphilis. The eruption comes out in crops, tends to persist for months if 
untreated, but finally undergoes involution in the same manner as the non- 
scaly papule and leaves the same kind of pigmentation. Involution seldom 
occurs in all the lesions at once, so that often they may be seen in all stages, 
especially when they are numerous and extensively distributed, as is the case 
frequently. The favorite sites for the more marked scaly papules are the 
face, along the eyebrows, at the margin of the hair, about the mouth, nose 
and chin, on the palms and soles, and the flexor aspects of the limbs and 
trunk. No part of the surface, however, is exempt from the liability to this 
form of syphilide. The lesions are usually discrete, but occasionally coalesce 
on the lower part of the face and in the neighborhood of the genitals. 

Another modification of the large papule is characterized by progressive 
peripheral enlargement until it reaches the size of a coin, sometimes an inch 
in diameter, and is termed the nummular syphilide. These lesions may be- 
come scaly or undergo repeated desquamation, leaving a scaly fringe at the 
border; they present well-defined and sometimes elevated margins, which, 
together with a slight depression in the central portion, may give them an 
umbilicated appearance. The process of involution may go on in the central 
part to completion, leaving a hard, scaly ring of infiltration bounding an 
atrophic and depressed centre. Thus the nummular is transformed into the 
annular or circinate syphilide. Adjoining ring-shaped lesions may meet 
together and by fusion at the points of contact form figurate or gyrate-shaped 
lesions, which, covered with thick, whitish, friable or compact scales, strik- 
ingly simulate the same shaped lesions of psoriasis. 

The circinate syphilide (orbicular syphilide) is sometimes formed by a 
linear mergence of smaller papules arranged in the form of a circle or seg- 
ment of a circle. These and other sinuous rows of papules may, by union, 
form various festooned or figured lesions. Sometimes a large papule is sur- 
rounded by a row of smaller papules known as the stellate syphilide. Indeed, 
the multiple forms resulting from the intermingling and union of the primary 
and transitional forms of the papular and papulo-squamous syphilide are as 
remarkable as they are rare. Many of the common circinate syphilides are 
attributed by Unna to the combination of the seborrheic process and syphilis. 
Where the sebaceous glands are abundant their secretion often mingles with 
the product of the syphilitic lesion and broken down epithelium and forms 



396 SYPHILIDES 

a crust, constituting a form of papulo-crustaceous syphilide. These are most 
often seen on the hairy parts of the face. In favoring locations, as about the 
genitals, mouth and alse of the nose, there may be added to the epidermic 
overgrowth more or less papillary hypertrophy, producing warty vegetations 
covered with scales and sebaceous matter. 

Papulosquamous syphilide of the palms and soles is so different from the 
same lesion elsewhere, owing to structural peculiarities of these parts, as to 
usually receive a separate description. Unlike other papular syphilides, it 
has no definite limit as to the time of appearance. If it develops in the first 
year it is apt to form only a part of the syphilitic eruption and is easily recog- 
nized ; more often it appears in the second year and is persistent under treat- 
ment. It may recur again and again for years. In a case of supposed syphilis 
of the nervous system, seen by the writer, these lesions were found on the 
soles of the feet, and the patient gave a history of a similar recurring erup- 
tion at4imes during the previous fourteen years since the primary infection. 
The resemblance to psoriasis of the same parts has led to their designation 
as palmar and plantar psoriasis, though they may sometimes simulate eczema 
more closely. 

On the palm the lesion usually appears first in the central part as a 
slightly colored to a coppery red spot covered by the firm, translucent, scarcely 
elevated epidermis and varying in size from a pea to a cherry; at an early 
stage it may not be perceptible to touch, but soon the epidermis thickens, be- 
comes opaque, is gradually raised, splits up into lamellae or is thrown off in 
one mass. There is left a reddish, round or angular spot bordered by under- 
mined skin which by serpiginous extension or concentric growth may extend 
to the border of the palm or even creep up the side of the hand or into the 
interdigital spaces. The papules may remain discrete or coalesce together 
and form various shaped patches which tend to heal in the centre and extend 
at the periphery by the formation of fresh papules. Thus the whole palm may 
sometimes be involved. When the deeper natural lines of the palm are in- 
cluded in the lesion, fissures may form in their place, extending into the 
corium, and become annoying and painful. The habitual use of the hands 
and their exposure to various irritations tend to add to the chronic course 
of this syphilide. 

On the feet, which are habitually protected, the course, while presenting 
much the same features, is not so protracted for the reason stated, though 
fissures on the feet may be deeper, corresponding to the thicker epidermis and 
become sometimes the seat of an obstinate ulceration. 

Occasionally the papulo-squamous syphilide of the palms (less often the 
soles) seems to expend its obvious force iipon the epidermis, and the corneous 
layer becomes piled up in hard conical elevations (corneous syphilide). These 
accumulations can be separated and lifted out of a crater-like cavity in which 
they seem to have been fixed. 

In the secondary period palmar and plantar syphilides are likely to be 
symmetrical ; in the later or advanced stages they may affect only one palm or 
sole and are probably often excited by some local irritation. 



SYPHILIDES 807 

Diagnosis of the papulosquamous syphilide of the secondary period is 
rarely attended with difficulty. 

From psoriasis it may be distinguished by the tendency of the syphilide to 
occur on the flexor surfaces of the body, on the face and neck, in lesions nearly 
uniform in size, and covered usually with dirt)' white, scanty scales, which do 
not completely conceal the color underneath and are easily detached without 
exposing red or bleeding points. Psoriasis, on the other hand, predominates 
on the extensor aspects of the body, particularly in its early evolution on the 
elbows, knees and on the scalp ; the spots are seldom uniform in size, are often 
nearly or quite covered with abundant, pearly, adherent scales, which if forcibly' 
removed leave red or bleeding points. Moreover, in psoriasis there is a history 
of a long course or of previous attacks of the same form of eruption. In the 
later stages a few lesions of the papulo-squamous syphilide may assume in 
course and configuration nummular, circinate, figurate shapes, so closely like 
the characteristic forms of psoriasis as to require the greatest care in differentia- 
tion. But a minute examination will rarely fail to show the differences in 
scales and base of the lesions above noted; the darker (coppery) red color of 
the syphilide, the succeeding pigmentation, which, together with the history 
of onset and course, will make clear the diagnosis. It is to be kept in mind 
that pigmentation sometimes occurs at the sites of psoriatic lesions, especially 
when the patient has had a long course of treatment with arsenic. 

A symbiosis of the syphilitic seborrhceic process in the skin may result in 
lesions very similar to those of seborrhceic dermatitis. The latter may be 
excluded by the history or presence of specific chronological or associated symp- 
toms of the syphilitic infection. 

On the palms or soles the late papulo-squamous syphilide may be easily mis- 
taken for psoriasis or eczema. Psoriasis rarely invades these parts, and is 
extremely rare without typical lesions elsewhere on the body. It shows no 
tendency, like the syphilide, to begin in the centre of the palm. By some a 
psoriasiform condition of the palms is considered pathognomonic of syphilis. 

Squamous eczema and syphilis of the palms and soles are more likely to 
simulate each other. Eczema of the palms, however, almost invariably begins 
between or at the roots of the fingers, on the wrist or dorsal surface, and thence 
spreads to the palm ; it pursues a slow, more even course, the infiltration merg- 
ing usually at the periphery in a hyperaemic redness of the adjacent skin, and it 
is attended with pruritus, often with the presence or history of moisture, dis- 
charge and crusting. Syphilis commonly begins in the palm and spreads 
outwardly by the development and coalescence of new papules, forming at the 
periphery an irregular and abruptly defined border of infiltration next to the 
sound skin. In long standing cases the distinguishing differences may disap- 
pear and it may be impossible to differentiate the two affections without first 
witnessing the effect produced by specific treatment. 

The moist papular syphilide (mucous patches, condylomata lata) is a mod- 
ification of the papular form of syphilide due to location on warm, moist and 
often unclean surfaces of the skin, more frequently near the mucous outlets. 



398 SYPHILIDES 

It is more commonly seen in women than in men, and may be the only outward 
evidence of the disease in the former. These lesions are frequently seen at the 
junction of the skin and mucous membranes of the anus and vulva, in the 
natural creases and on opposing surfaces of warm or moist parts, as under 
the breasts, about the genitals, in the inguinal and axillary regions, between 
the toes, etc. These lesions are very contagious and a common source of infec- 
tion. They occasionally originate from an erythematous or eczematous surface 
without the papular formation. Ordinarily they arise from papules due to 
considerable papillary infiltration and free proliferation of the cells of the 
mucous layer of the epidermis, and may be small or large elevations up to a 
half inch in diameter. Usually the epithelial covering becomes transformed by 
heat and moisture into a grayish membrane, which separates or is accidentally 
removed, leaving an eroded, soft, moist, reddened surface, similar to a mucous 
membrane ; hence the term mucous patch. Local irritations, friction and other 
influences incident to location and habits, as well as the treatment employed, 
largely determine the further course of the moist papule. It may rapidly dis- 
appear under care and treatment; left to itself it may take on a diphtheroid 
covering, or become crusted over with the dried secretion and epithelium. 
Sometimes ulceration follows and it is depressed below the surface, and the 
source of an offensive secretion. Again, it may take on a papillary growth, 
especially about the arms and genitals, which elevates it about the tenth of an 
inch above the surface, constituting a vegetating lesion known as condylo- 
mata lata. These may coalesce more or less to form irregular cauliflower-like 
patches, furrowed with fissures, and in the uncleanly, especially between the 
toes, yield a brownish and foul secretion. 

Moist papules are usually seen only in the secondary period of syphilis, but 
they may appear later, even in the late tertiary stage. In all cases they tend 
to persist and relapse for weeks or months, and untreated may continue indef- 
initely. Mucous patches, unlike other syphilitic eruptions, are sometimes the 
seat of itching, especially where they are exposed to friction or pressure. 

Diagnosis of the moist papules and condylomata is rarely attended with 
difficulty. Their situation in certain regions, mode of development and form, 
together with other lesions and concomitant symptoms of syphilis make their 
nature plainly apparent in most cases. Non-syphilitic venereal vegetations 
usually overlap their base and are distinctly branched or pedunculated. The 
syphilitic vegetations are as broad at their bases as on their outer surfaces. 
Rarely when subject to pressure the non-syphilitic papillary growths may pre- 
sent a closer resemblance to the syphilitic, and the associated symptoms and 
history of the case will be needed to establish a positive diagnosis. At the 
margin of the anus mucous patches may be mistaken for simple anal fissure. 
The former has more rounded and fuller edges, and is often covered by a gray- 
ish film or pellicle. 

III. The pustular syphilides. — This group of eruptions are less common 
than the erythematous and papular syphilides, but important from their varia- 
tion in size, number, mode of evolution, time of appearance, and in resemblance 




Fig. ll'_\— MOIST PAPULAR SYPHILIDS 

CONDYLOMATA 

Female subject, associated with a cellulitis of the vulva. The coalescence of t 
number of lesions formed the cauliflower-like patch shown in the illustration, own 
pying a large portion of the perineum. 



SYPHILIDES 899 

to simple lesions. They vary in size from a pin-point to a dime, are round or 
oval and surrounded by a coppery zone; they may originate from papules or 
be primarily pustular and occasionally develop as a rapid transition from the 
vesicular. They may cover the entire body or be limited to certain regions; 
they may be superficial, leaving no trace behind, or ulcerate and produce scars. 
The crusts which form from the small pustules are greenish-brown in color, and 
beneath there is little or no suppuration; the crusts of the larger lesions are 
greenish-black and cover well-marked ulcers, secreting thick, dark yellow pus. 
They commonly appear as secondary manifestations of syphilis, but they may 
be prolonged into or recur in the tertiary period. The early occurrence of a 
pustular syphilide is indicative of a bad type of the disease or some condition 
of the patient favoring suppuration, and in proportion as the lesions are large, 
numerous and deep-seated is the tendency to precocious or malignant syphilis. 

The so-called vesicular syphilide is included in this group, for the very 
good reason that all syphilitic vesiculation is transitory and always passes into 
the purulent type. Pustular syphilides may be divided into the varicellaform or 
variolaform, impetigoform, eethymaform, rupial and pemphigoid. 

The varicellaform or variolaform syphilide is an infrequent form, chiefly 
characterized by its resemblance to the eruptions of variola or varicella. It 
begins usually after some of the early eruptions of secondary syphilis, shows a 
preference for the forehead, face and flexor surfaces, and lasts from four to 
six weeks unless prolonged by successive crops. At first the lesions appear as 
red spots, which soon become elevated by a serous or sero-purulent effusion 
underneath the overlajdng epidermis. With the serous and pustular transfor- 
mations they assume a conical shape and are surrounded by a well-marked 
coppery areola. When mature they are pea sized or slightly larger, but soon 
shrink, become flattened, often umbilicated, and in a few days dry into 
greenish-brown, slightly adherent crusts underneath which is superficial ulcera- 
tion. 

Ultimately the crusts fall off, leaving reddish-brown depressions. When 
the lesions remain discrete they may have a close objective resemblance to the 
eruption of chicken-pox. In other cases the lesions at an early stage pass into 
shotty, umbilicated papules and papulo-pustules identical in location and 
appearance to the eruption of smallpox. In fact, many cases of this syphilide 
have been mistaken for variola and sent as "suspects" to smallpox hospitals. 
This variety rarely appears before the third month and may appear as late as 
the second year. The onset is usually slow, it runs an indolent course, gen- 
erally without increase in size or coalescence of the lesions. In the neglected 
or debilitated this syphilide may cause deep ulcerations and consequent 
cachexia. 

The diagnosis, notwithstanding the striking resemblance of this syphilide 
in many cases to a varicella or variola, is commonly made without difficulty. 
The absence of the prodromal symptoms*and attendant fever of the latter and 
the slow development of the syphilide are distinctive points. Sometimes the 
onset of the syphilitic eruption is accompanied by marked febrile disturbance, 



400 SYPHILIDES 

but the history of the case and a delay of a day or two, at most, would show the 
characteristic changes of the more acute exanthemata. Varicella is a disease 
of childhood and syphilis usually of adult life. 

The acneform syphilide simulates acne vulgaris, in that it attacks the hair 
and sebaceous follicles and develops into like papulo-pustular lesions. This 
eruption generally appears from the third to the sixth month of the secondary 
period, and is often attended with considerable fever which may persist for days 
or weeks. The lesions are most numerous about the face, back of the shoulders 
and neck, on the scalp and outer aspect of the extremities, but may extend to 
other parts of the trunk and extremities ; often the invasion occurs by successive 
stages from the regions of the head and shoulders to other parts of the surface. 
The lesions remain usually discrete as they become disseminated over different 
regions, acne syphilitica disseminata. Later outbreaks are more apt to be 
grouped in certain regions, and very rarely they become confluent or take on 
a verrueese appearance. 

The lesions consist of small conical or rounded papules which soon become 
yellow at the apex, to which the pustulation is confined, while the base is first 
a bright red, soon deepening to a brownish hue. The onset of the eruption 
may be rapid or sub-acute, and the pustulation correspondingly immediate or 
only after the papules have existed for several days. Miliary papules and 
erythema may precede or coexist with the acneform lesions. The thin greenish- 
brown crust which forms at the apex is in many cases cast off, leaving a papule 
which continues to desiccate on the surface as involution takes place. Some- 
times a collarette of exfoliation is seen about these as in the typical papular 
syphilide. A small pigmented spot remains for some time after the disap- 
pearance of the infiltration. Occasionally ulceration may occur, the pustule 
increases in size, involves the derma and results in the production of a scar. 
The duration of this syphilide is usually from six to ten weeks, but may be 
prolonged by successive crops for months. The eruption is always more copious 
at first than in the relapses, and, beyond the limits of its course, recurrences 
are apt to be in larger and deeper lesions. 

Diagnosis. — Acne vulgaris may be excluded by its usual appearance at or 
about puberty, its limitations to a certain region, absence of constitutional 
symptoms, presence of comedones and. a variation in the size of the lesions, 
some of which may be little follicular abscesses whose contents can be pressed 
out. Whereas the acneform syphilide generally occurs in adults, is more or 
less generalized; its lesions more uniform in size; the invasion is attended with 
systemic fever, is not associated with comedones, the pustulation only occurs 
at the apex of the papules and other signs of S3^philis are usually present. 

Iodic and bromic acne might be mistaken for the sj^philide, but the absence 
of constitutional and other signs of syphilitic infection and a history of the 
use of either of these drugs or their compounds would serve to distinguish 
the former. 

The impetigoform syphilide is a rather common form of pustular eruption 
occurring during the middle or latter part of the first year of syphilis, and is 



SYPHILIDES 401 

characterized by the objective resemblance of the lesions to those of simple 

impetigo. In exceptional cases the eruption may appear in the second or third 
year, and in a severe or distinctive form it may occur as a tertiary manifestation 
of syphilis. The earlier lesions are usually discretely distributed over the whole 
body, but often predominate on the lace, scalp, genitals and extensor surfaces 
of the extremities. The later lesions are localized and grouped with a more 
marked predilection for regions named. The pustules originate from small or 
larger pea-sized infiltrations or flatfish papules, usually situated in the peri- 
follicular structures, the purulent exudation elevating the epidermis to form 
round or oval lesions. The pustular stage is short, but the resulting crusts 
are persistent, adherent, of a dark-brown color and surrounded by a narrow 
areola. If forcibly detached, a superficial ulcer is found beneath and the crust 
quickly re-forms. Undisturbed it may not fall off spontaneously until the 
local process is finished and healing occurs. Sometimes the crusts of several 
pustules may join together, especially on the face and scalp, forming a com- 
plete or incomplete crusted surface a half inch to two inches in diameter, which 
on the hairy parts is apt to be irregular in outline. The grouped pustules of the 
late period may unite and form large patches, usually remaining circular in 
form, but occasionally assuming a kidney shape. These transformations are 
rarely seen on the face, but more often on the forearm, thigh or on the trunk. 

In neglected or debilitated subjects this pustulo-crustaceous syphilide may 
progress superficially by a ring of ulceration underneath the edges or around 
the central crust, and sometimes extend over a large surface, healing meanwhile 
in the centre, leaving perhaps little or no injury to the skin behind. In other 
cases the extension may take place at one or more parts of the periphery while 
repair goes on at other portions of the patch, constituting in either case a form 
of superficial serpiginous syphilide. These variously shaped and "spreading 
lesions may become merged together and involve a large extent of surface. The 
spreading ulceration is apt to keep a circular form on the face, and an oval 
or more distinctly serpiginous form on the arms and trunk. This form of pus- 
tular syphilide may occasionally lead to deep ulceration of the skin, varying in 
extent. Underneath the crusts the destructive process may involve the entire 
thickness of the skin. Kemoval of the crust exposes a deep, excavated ulcer, 
with abrupt edges and a red, uneven floor covered with secretion, which soon 
dries into a new crust. It is sometimes called impetigo rodens when it occurs 
in the cachectic or strumous, and resembles similar lesions of the tertiary period. 
It is seldom seen in those who receive appropriate treatment. 

The course and duration of this syphilide is nearly always chronic. The 
number of the lesions present at one time may be few, and new pustules may 
continue to appear for a long period .as the old ones fade. Occasionally the 
rash is abundant and runs a shorter course. It may be associated with any of 
the other types of eruption of the secondary or even of the tertiary stage. A 
few pustular lesions are not infrequently seen near the termination of a papular 
syphilide. 

A diagnosis of the impetigoform syphilide can usually be made without 



402 SYPHILIDES 

difficulty. It may be distinguished from the eruptions of smallpox by the more 
acute and severe onset of the latter, and the more rapid evolution of its lesions. 
From impetigo simplex, by the more rapid invasion and course of the latter, by 
the disappearance of the areola when the crust forms in impetigo; its yellow 
crusts more dense and adherent than in the syphilide. Impetigo eruption is 
usually attended with some symptoms of heat and itching ; these are absent in 
the syphilide, while other signs of syphilis can be generally found. From 
pustular eczema the confluent syphilide may be recognized by the absence of 
subjective sensations, its more abruptly defined patches and darker crusts com- 
monly covering points of ulceration. 

The ecthymaform syphilide is a type of pustular eruption which occurs in 
a superficial and deep form, the former often exhibiting a marked resemblance 
in form and location to non-specific ecthyma. It is usually a late secondary 
accident, but may appear at any time during this period, while the deep form is 
always a late manifestation or a feature of precocious syphilis. 

The superficial form, as a rule, is found most abundantly on the legs, but 
may be freely distributed about the neck, buttocks, inguinal regions and, rarely, 
there may be lesions on the trunk. The pustules arise from red infiltrations in 
the skin ; they are small and conical at first, but increase in size with the per- 
ipheral extension of the infiltration, and progressively dry into crusts of a 
yellowish color. These become brownish or even darker from admixture of 
dirt and sometimes of blood. As the crusts grow in size with the base of the 
pustule they become flat and sometimes depressed in the centre. Beneath the 
crust superficial ulceration goes on until the crust is thrown off, leaving a red 
and often slightly papillated surface, which may again become covered with a 
thin epidermic crust, or remain scaly for a time during the completion of the 
reparative process. The copper colored areola may be a long time in fading 
away. These superficial lesions rarely exceed a third of an inch in diameter, 
except under unfavorable conditions of the system, when they may increase 
singly or by union to the size of an inch or more. The course and duration of 
this syphilide is much the same as the spreading impetigo form. It may develop 
in a week, or continue to appear in crops for a month or more. Occurring as an 
early accident the lesions are apt to be numerous and symmetrical ; as a late 
eruption they may appear without symmetry and be limited to one region. 
Their decline may or may not be succeeded by scars. 

The deep variety of the ecthymaform syphilide is rarely seen in the secon- 
dary period, and is then usually indicative of precocious or malignant syphilis 
and attended with marked cachexia. More often it is a late lesion. It begins as 
a round or oval elevation or papulo-tubercle of the skin which soon breaks down 
into a yellowish pustule. This may become darker from admixture of a little 
blood and dries into a brownish-black crust, which may remain conical or flatten 
out as it increases in size. Beneath the crust may be found a deep ulcer with 
sharply cut edges, with a foul, brownish colored secretion covering a smooth, 
grayish floor. The base of the ulcer consists of firm, infiltrated tissue of a deep 
red color, with sometimes an extending line of ulceration at the periphery, not 



SYPHILIDKS 403 

completely covered by the crust and surrounded by a deep coppery hued areola. 
These lesions may attain a half inch or more in diameter and in neglected cases 
continue to spread, assume a serpiginous form or merge together, and are often 
accompanied by hectic fever, etc. The process of repair, even in benign cases, 
is usually slow ; its termination is indicated by a lessening of the secretion, the 
appearance of healthy granulation and melting away of the border; crusts may 
cease to form or continue to the end of the process. A depressed coppery red 
cicatrix, representing in shape the area of previous ulceration, is left, which 
gradually pales into a glistening white spot. This syphilide generally develops 
slowly in crops of a few lesions, at intervals of seven to twenty days, and may 
pursue a sluggish, insidious course for months. The eruption is most common 
on the anterior and outer aspect of the legs, on similar regions of the arms, the 
lower parts of the trunk and on the face. 

The diagnosis of the ecthymaform syphilide is seldom difficult. Non- 
specific ecthyma may be excluded by the absence of a bright red inflammatory 
areola and pruritic sensations, presence of more extensive ulceration, darker 
and thicker crusts, greater variation in the size of the lesions and other evidences 
of syphilis. 

Ecthyma cachectica with a livid areola can be distinguished from the deep 
ecthymaform syphilide, in the absence of other signs of syphilis, by their super- 
ficial though perhaps more extensive character, more distinct inflammatory type 
and wider areola. Varicose ulcers may be mistaken for the deep ecthymatous 
syphilide, but attention to the histor} r of development, presence of varicosis, 
pains, and an absence of other evidences of syphilis will help to exclude the 
syphilide. The unhealthy sore sometimes found in chronic phtheiriasis may be 
distinguished by the presence of blood crusts due to the bites of the insects, as 
well as by the discovery of the latter in the seams of the underclothing. 

The rupial syphilide, as a characteristic eruption, occasionally appears pre- 
cociously in the secondary period and is preceded by febrile symptoms, but it 
is usually a tertiary manifestation of constitutional syphilis. It begins, like 
the ecthymatous form, as a red infiltrated spot, which is soon transformed into 
a flat pustule. The thickness of the pus causes it to dry- rapidly into a greenish- 
brown crust. As the ulcer underneath the crust spreads beyond its edges 
another layer of desiccated secretion is formed wider than the first and elevating 
the latter. Thus the process of ulceration and incrustation may very slowly 
progress until a large, round, conical, firm, laminated, adherent crust is formed, 
a third of an inch to one or two inches in width. At the acme of its formation 
the rupial crust is of a greenish-brown or black color, and from its peculiar 
structure resembles the outer surface of a dirty oyster shell. Earely these 
lesions reach extreme dimensions of several inches in diameter. Underneath 
a crust forcibly removed is found a rather superficial ulcer with a grayish- 
red base and moderately undermined edges, secreting an unhealthy, thick, 
serous pus, intermixed with blood ; around each ulcer is a coppery areola which 
merges outwardly into the sound skin. Rupial lesions may be generally dis- 
tributed, but they are more commonly seen on the arms, face and neck, and 
are more likely to attain a large size when few in number. 



404 SYPHILIDES 

The course of a rupial syphilide is very slow. It frequently appears in 
crops of a few lesions at short intervals, and may continue for months to a 
whole year unless cut short by treatment. When a lesion exceeds an inch in 
diameter its later growth is extremely slow. When repair is advanced the 
crust falls off, leaving a healthy granulated base which becomes converted into 
a depressed, smooth or netlike, white, shining scar, which remains surrounded 
for some time by the remaining coppery areola. These cicatrices are often per- 
forated by minute holes, the openings of sebaceous glands. Eupial lesions are 
pathognomonic of syphilis, and no doubt in diagnosis is likely to arise if care 
is exercised in the examination. 

The pemphigoid syphilide (the bullous syphilide) is a variety which, owing 
to its rarity and ephemeral character, holds an uncertain place in the classifi- 
cation of the syphilodermata. The serous effusion almost invariably, if not 
always, becomes purulent, and sometimes is transformed into the ecthymatous 
or rupial syphilide; therefore, it may with good reason be grouped with the 
pustular class. 

It begins very much like true pemphigus by an effusion of serum beneath the 
epidermis, which slowly increases to the size of a pea and upwards, rarely attain- 
ing the size of a walnut. The contents meanwhile become turbid, and are trans- 
formed finally into a thick pus. The lesion is surrounded by a deep red areola, 
and the pus dries into an adherent greenish-black crust. In the debilitated or 
cachectic the ulceration underneath may increase and a rupial form of lesion 
result. Ordinarily the superficial ulcer cicatrices underneath the crust, which 
falls off, leaving an atrophic, deeply stained spot. In some mild cases there may 
be no objective differences between these bullous lesions and those of true pem- 
phigus, which have led some observers to hold the view that these lesions 
are due to intercurrent pemphigus in the course of syphilis. The eruption is 
often confined to the palms and soles, forearms, legs or chest : rarely it may be 
widely spread. It is nearly always a late accident of syphilis and usually indi- 
cates a severe form of the disease ; it may be a feature of relapses, and in those 
suffering from internal syphilis. 

A diagnosis of this syphilide may be made on the history of the case, 
presence of the concomitant symptoms of syphilis and in doubtful cases on the 
effects of specific treatment. 

IV. The tubercular syphilides. — Two forms of the tubercular syphilide 
are recognized, the tubercle and the gumma. Alike histologically, they differ 
only in depth and extent. The tubercle is a deep intradermal infiltration too 
large to be classed as a papule. The infiltration which constitutes the gumma 
involves the subcutaneous tissue. Both lesions are typical of the tertiary or 
late stage of syphilis, and usually appear in the first few years after the sec- 
ondary period, but may occur much later, perhaps after freedom from all 
cutaneous manifestations or even without any history or previous disease 
("ignored syphilis"). One of my own cases had a gumma of the nose twenty- 
two years after the primary sore, and I have seen several cases in the clinic 
with tertiary lesions from whom no history of primary or secondary syphilis 



SYPHIUDES 105 

could be obtained. The so-called tertiary stage of syphilis may be termed 
the unnecessary, uncertain and chronic period of the disease, and is probably 
due in most cases either to so mild primary and secondary symptoms as to be 
overlooked or neglected, to some depraved state of the system or to want 
of sufficient treatment. The lesion.- common to late syphilis mav occur pre- 
cociously in the first two years of the disease, even in the Becond or third month 
when the macular or papular eruption is still present. They are then always 
a sign of a severe or anomalous form of the disease and mav pursue a more 
rapid course. 

The tubercle or gumma occurring in the tertiary period differs from the 
eruptions of the. secondary stage in the absence of general or local prodromata. 
in the lack of any definite order or time of appearance, in the smaller number 
and want of symmetry of lesions; in their deeper development, uncertain seat 
and isolation; in their insidious growth by slow and dense cell infiltration, 
usually without tendency to resolution, but a final proneness to degeneration 
and destruction of the parts involved; and in their not infrequent associa- 
tion with syphilis of the viscera or other parts. These and other varying 
peculiarities of the tertiary accidents are never exhibited alike in two cases, 
hence any didactic description of their clinical history must be incomplete. 
As a rule late tertiary lesions do not posses- infective properties, but just when 
the syphilides cease to be infective is uncertain and probably variable. While 
they may occur upon any portion of the body and mucous tracts, they are more 
common on the face, back of the shoulders and on the extremities. 

The tubercular syphilide anatomically occupies an intermediate position 
between the large papule and the gumma. Unlike the papule, it involves the 
whole thickness of the skin, but does not penetrate into the subcutaneous tissue 
like the gumma. 

The lesions commence as deep red spots which gradually enlarge in all 
dimensions until they reach the size of a split pea or from relatively large 
lateral growth to a half-inch or more in diameter. The smaller lesions are 
more rounded and elevated and the large ones more flat and less raised. In 
color they vary from a pinkish-red to a dark red, with a shining surface on 
some parts where the skin is thin, and on thicker portions they may have a 
dull rough or even scaly surface. When the scaliness of the flat tubercles 
is considerable they may resemble psoriasis. They are apt to appear first 
on the scapular region of the neck, on the forehead, about the alaa of the 
nose, ears and may be discretely scattered or distributed in irregular triangles 
or circular shapes; situated along the brow near the scalp they constitute a 
variety of corona veneris. They may invade the trunk and extremities and are 
then more abundant on the back, gluteal regions and on the outer aspects of 
the legs and arms near the joints. The nearer their occurrence to the sec- 
ondary period the more copious and general is the eruption likely to be. As 
a late manifestation the outbreak may be confined to one region and the lesions 
few in number. From the third to the sixth year is their most common period 
of occurrence, but they may appear early, even in the first and second years, 
or late as the tenth or twelfth year and rarely later yet. 



406 SYPHILIDES 

The eruption is not attended with any subjective symptoms and its 
course is usually very slow. The development of new tubercles and the indolent 
involution of the old ones may carry the duration into months or years. The 
behavior of the lesions varies widely in different cases according to their mode 
of evolution and involution. They seldom ulcerate, they may run together 
and form variously sized and shaped patches with elevated borders, depressed 
and clearing centres, constituting a variety of the annular syphilide. When 
the process of extension and resolution is rapid little damage may be in- 
flicted on the skin; if slow, more or less atrophic scarring is left. Some- 
times after several tubercles unite the extension may occur serpiginously. 
Thus from a coalescence" of lesions on the nose butterfly-like extensions may 
occur out on to the cheeks. In the large number of cases the eruption has a 
circumscribed circular or crescentic outline which extends by new papules 
appearing at the periphery. Occasionally a large part of the face may be 
invaded—by the syphilitic process. On the non-hairy part the patches are 
comparatively smooth, on the hairy surfaces they may be uneven from the 
greater involvement of the follicles and papillae. If the latter become ex- 
cessively hypertrophied there may appear the same papillomatous or vegetat- 
ing type of syphilide already mentioned as originating from the papular 
lesions. A little pus may form and dry into crusts between the elevations 
or an exudation of serum dry into crusts over the surface. Barely the hyper- 
trophy of the integument of the face may become enormous and simulate 
leprosy. In other rare cases some tubercles may undergo colloid degeneration 
and appear as if saturated with glue. The course of the vegetating tubercular 
syphilide is very protracted. 

On the palms and soles the tubercles become scaly and constitute one form 
of syphilitic psoriasis. They may form circles with a fringed border and a 
coppery areola. 

The involution of the non-ulcerative tubercle occurs through a simultaneous 
degeneration and absorption of the syphilitic infiltration and the fibrous struc- 
ture of the derma which holds it. This process and the replacing cicatricial 
formation goes on underneath an unbroken and perhaps slightly changed 
epidermis. In this retrograde process the rounded tubercles flatten and sink in 
the centre, and may thus be transformed into tubercular rings which are finally 
effaced. Beginning with the involution, the color of a lesion fades from a red 
to a brown, and as it disappears leaves a grayish pigmented spot, which is finally 
replaced by a whitish cicatricial depression. The shape and extent of the ulti- 
mate cicatrices will depend upon the preceding lesions, the appearance of new 
tubercles while the earlier ones are being resorbed, and also on early and effec- 
tive treatment. When treated early it is possible for this syphilide to disappear 
without injury to the skin. Nearly always some scarring results and in neg- 
lected cases there may be considerable loss of tissue without a sign of ulcera- 
tion. Thus the lobes of the ear and the alse of the nose have been destroyed by 
the atrophic process. 

In a minor number of cases some part of the tubercle may ulcerate and is 



SYPHILIDES 407 

then sometimes termed the ulcerative tubercular syphilide. It differs from the 
non-ulcerative only in the method of involution. In place of the absorption 
process of the latter the tubercle softens in the centre, breaks down the epidermis 
over it and becomes covered over with a quite thick yellowish crust. This 
crust slowly turns to a greenish-black and is surrounded by a deep red or pur- 
plish areola. The size of the crust represents the area of the ulcer which it 
covers. When the crust is removed this is usually found to be deep with a 
thick border, sharply cut and sometimes slightly undermined edges, a smooth 
floor and secreting and irritating foul pus. The subsequent course of these 
ulcers varies with their location, the general and tissue health of the patient and 
the intensity of the inflammatory process. In the cachectic, debilitated and 
alcoholic, the ulcers are apt to spread and join together in large patches. In the 
well nourished they may remain circumscribed and ultimately leave no greater 
cicatricial blemish than in the resolutive tubercles. The more common locali- 
zation of this syphilide is upon the face, shoulders and neck and less often on 
the extremities and trunk. 

On the face it may be attended with considerable inflammatory swelling and 
hypertrophy, and sometimes pursues a rapidly destructive course. This is espe- 
cially marked when the process becomes phagedenic or gangrenous in character. 
In extreme cases the nose may be penetrated and its entire structure, with the 
soft parts about, destroyed in a few weeks. These ulcerations may advance by 
peripheral infiltration and consecutive breaking down, or by new individual 
tubercles forming near their border ; in either way the tendency is to maintain 
circinate shapes. Wherever situated, however, they often assume a serpiginous 
method of growth by new tubercles developing at the margin, while progressive 
cicatrization goes on in the centre. The latter mode of combined evolution and 
involution, as well as the exceptional appearance of keloidal tubercles in the 
cicatrices of syphilis may present a close objective analogy to lupus vulgaris. 
Hence the origin of the term syphilitic lupus. 

The lesions of the ulcerative tubercular syphilide heal very slowly, as a rule. 
When repair is sufficiently advanced crusts cease to form and an irregular, 
reddish cicatrix is left, which finally fades to a shining white color often sur- 
rounded by a narrow coppery areola for some time. Such scars are usually 
depressed relatively to the depth of the preceding ulceration, and in some cases 
following deep ulceration they are traversed by fibrous bands. Sometimes 
keloidal growths appear in the cicatrix, and the superficial scars may be per- 
forated by the minute, openings marking the seat of follicles. 

When this eruption occurs early, as in precocious syphilis, it may coexist 
with other cutaneous and non-cutaneous manifestations of the secondary period. 
Statistics indicate that the exulcerative tubercle constitutes about one-quarter 
of the tertiary syphilides. Its course and duration may be greatly modified by 
treatment. Neglected cases may result in extensive destruction of tissue with 
consequent cicatricial disfigurement, and are often accompanied with marked 
cachexia and sometimes with visceral symptoms. 

Diagnosis. — The tubercular syphilide may be mistaken for the lesions of 



408 SYPHILIDES 

lupus vulgaris, leprosy, psoriasis, eczema of the palms and the tubercles of acne 
rosacea. 

Lupus vulgaris lesions may be closely simulated by this syphilide, but lupus 
commonly begins in early life, is often limited to one region and is never as 
widely distributed as the syphilide. Lupus is much slower in its development and 
progress, has less regular lesions surrounded by an inflammatory redness which 
merges gradually into the sound skin, unlike the well-defined coppery areola of 
syphilitic tubercles. The color of the lupus tubercles is pinkish or violet, of 
apple jelly consistency, and milia-like colloid points may be found sometimes 
about or on the lesions. The ulcers of lupus are not so sharply cut or regular 
as in the syphilide ; the crusts are irregular and do not have the greenish-black 
color of the latter. Eepair is much slower in lupus, and the scars when formed 
are hard, uneven, more adherent and less depressed than the smooth, thin, 
flexible and sunken scars of syphilis. For other differences see lupus of 
the face-. 

Leprosy tubercles may resemble those of syphilis, especially when the latter 
are hypertrophic and similarly located about the face. The leprosy growths 
are larger, softer and usually accompanied by large patches of brownish pig- 
mentation, white anaesthetic spots and other disturbances of sensation in or 
about the lesions not found in syphilis. Besides these differential points, resi- 
dence in a leprous country, duration, etc., will help to clear up the diagnosis. 

Psoriasis may be differentiated from the tubercular syphilide of the palms 
or soles in the same way as the papulo-squamous form. 

Chronic palmar eczema and this syphilide may look much alike. Eczema 
is nearly always characterized by a history of or the presence of serous exudation, 
greater crusting, Assuring and an ill-defined border accompanied with pruritus. 
The syphilis lesions are abruptly defined, often infiltrated and fringed at the 
border, surrounded by a coppery areola and unattended with subjective sensa- 
tions unless irritated. Either disease may show more characteristic lesions else- 
where on the body. 

The tubercles of rosacea will seldom be mistaken for those of syphilis. The 
nodules of the rosacea arise in congested and thickened skin, frequently after 
a history of long persisting redness, followed by dilated capillaries which become 
tortuous and permanent. The tubercles are uneven, have no tendency to destroy 
tissue by degeneration or ulceration and are generally limited to the nose, 
middle third of the face and forehead. The presence of a few of these features, 
especially in connection with a long course, would serve to exclude uncompli- 
cated syphilis. 

The gummatous syphilide always begins in the subcutaneous tissue, unlike 
the tubercle which begins in the derma, but, like the latter, is made up of a 
solid cell infiltration. It is always circumscribed by a hardening of the con- 
nective tissue about it, but varies greatly in size — from a pea to an egg, or even 
larger. In shape it may be globular when situated in the loose tissue, flattened 
when formed beneath the scalp and oblong where there is lateral restriction, 
as along the fingers. When a syphilitic gumma is of large extent it is usually 



8YPHI1IDEB Wfl 

due to a union of several lesions; generally they remain isolated and rarely ;i 
single tumor may be of large dimensions. Gumma are more apt to form in 
regions where the connective tissue is abundant, and where there is considerable 
deposit of fat it may remain a long time without extending to the skin. When 
the part affected is firmer and especially over bone and fascia the skin mav he 
involved early and the parts beneath attacked and ultimately destroyed. 

Involution of the gummatous tumor may occasionally take place without 
ulceration and leave little or no trace behind, but when the skin is secondarily 
attacked ulceration occurs as a rule and the tumor is transformed into a gum- 
matous ulcer. 

This syphilide is nearly always a late lesion, rarely occurring before the 
fourth year and sometimes not until after the twentieth or thirtieth, year. 
Exceptionally it may appear in the earlier months in malignant types of the 
disease. 

Most gumma have three fairly distinct stages — of infiltration, of ulceration, 
and of repair. 

In the stage of infiltration there is a slow growth of one or more tumors. 
The number is usually in inverse ratio to the lateness of occurrence. Even in the 
early years they are rarely numerous, not often exceed eight or ten, though cat 
have been recorded where there were thirty and upwards. Exceptionally, also, 
they may develop symmetrically and quite rapidly with accompanying general 
symptoms of the secondary period. In the later period they are asymmetrical 
and unattended by general or local disturbance beyond a moderate soreness in 
restricted or exposed situations. "When fully developed they appear as sub- 
cutaneous, firm, rounded nodules, at first freely movable between the parts 
beneath ; thus they ma} T remain for weeks or months. In their further progress 
they tend to invade the skin rather than the deeper tissues. This advancement 
is shown by the skin losing its suppleness, becoming thicker, reddened and at- 
tached to the tumor. Soon a hypersemic areola appears around the coppery-red 
and perhaps elevated centre. Again, the lesions may remain stationary for a 
time and under treatment disappear without ulceration. In a recent case 
under the author's care a gummatous tumor of the upper lip, the size of an 
almond nut, which had gone slightly beyond the point described above (the 
most elevated portion of the skin having flattened from the softening beneath"), 
entirely disappeared under treatment without a break in the surface of the skin. 

Generally the stage of tilceration succeeds the formative one: the softened 
and undermined skin breaks in the centre and gives exit to a thick, viscid 
product of disintegration mixed with blood. Gradually the slough-like sub- 
stance of the neoplasm is eliminated through one or several openings, leaving 
exposed a gummatous ulcer. The gummatous ulcer is more or less deep and 
wide according to the extent of the original tumor ; it is round, oval, or irregular 
(from the fusion of several small lesions), with thickened borders surrounded 
by an extensive areola,. undermined walls, an uneven greenish-red or blackish 
floor covered with broken down tissue and bathed by a sanious, fetid, purulent 
secretion from the walls of the cavity. 



410 SYPHILIDES 

The course of such ulcers varies with their location, the care they receive and 
the intercurrence of inflammatory, gangrenous or other processes. Sometimes 
they pursue a phagedenic course, involving extensive areas and producing a 
severe or alarming cachexia. In a few cases they may remain indolent, with 
considerable swelling of the adjacent tissues, an offensive discharge and without 
any tendency to heal. In any case repair cannot occur until complete removal 
of the abnormal tissue, spontaneously or by treatment. Then healthy granula- 
tions appear on the floor of the ulcer, the thickened borders melt away and scar 
tissue forms over the surface. The consequent cicatrix is depressed and wide 
according to the depth and extent of the ulcer; it is usually smooth, but may 
be uneven from fibrous bands or nodules, is often adherent, white in the centre 
and a brownish hue at the periphery. The favorite seats of gumma are the 
middle and upper third of the legs, about the ankles, the scalp and forehead. 
They ma3 r , however, occur upon any part of the body, but only with extreme 
rarity jm the palms or soles. On the leg they are apt to be attended with 
osdematous, hypertrophic and inflammatory complications, sometimes destroy- 
ing the deep tissues to the bone. On the scalp they are prone to coalesce, involve 
the entire integument, become adherent to or damage the bone. Here, too, 
erysipelas is liable to supervene as a complicating process, as it sometimes does 
in gummatous ulcerations of the leg and face. Located on the face gummatous 
ulcers may not only destroy the soft parts, cartilages and bones, but even in the 
less severe cases may result in disfiguring scars which in some cases interfere 
with the functions of the eyes, nose or mouth. Such results are rare, however, 
in recent times, since few cases among the poor fail now to receive careful 
treatment. 

Where the connective tissue is abundant, as about the genitals and buttocks, 
gumma may extend to considerable depth or breadth. In the deep form ending 
in ulcerative degeneration, blood-vessels may be eroded and severe or fatal 
hemorrhage result. In rather unusual situations, as upon the back, in the 
breasts, etc., large gummatous tumors have been mistaken for other growths 
and sometimes unnecessarily excised. Cases have been recorded where gumma 
were situated on sensory nerves and caused pain, sometimes of a severe neuralgic 
character. Like all syphilides, the course of the gummatous is influenced by 
diathetic and other general or local tissue states. Syphilitic ulcerations in the 
scrofulous are likely to be indolent and intractable to treatment. Some local 
conditions may cause the ulcerating gumma to extend in a regular or irregular 
manner over a large surface, or in other cases take on a papillary growth. 
Likewise, gangrene or phagedena, as before mentioned, may contribute to the 
destruction of tissue, be attended with local pain and constitutional depression 
amounting sometimes to a typhoid condition. 

Diagnosis. — It is important to recognize gummatous tumors at the earliest 
moment in order to institute appropriate treatment to prevent ulceration and 
destruction of tissue, and to distinguish them from other neoplasms which may 
require surgical removal. A clear history of primary syphilis or the occurrence 
of other syphilides is often wanting as an aid to diagnosis, and chief reliance 



SYPHILIDES 411 

must be placed on the physical features and method of development of the 
gummatous tumors or ulcers. 

In the stages of tumefaction gumma may be mistaken for scrofulous swell- 
ings, sarcoma, lipoma, fibroma, etc. 

Enlarged glands and "scrofulous gummata" often have a clinical likeness 
to specific gumma. They more often occur in young subjects than syphilis, are 
generally situated quite characteristically along the line of lymphatics and 
pursue an indolent, persistent course. No history of syphilis can be obtained, 
and other signs of scrofula are usually present. 

Sarcomata do not have the favorite seats of gumma ; they more frequently 
occur on the trunk and become attached to parts beneath, while gumma seeks 
the skin; they are harder, painful, usually single and do not disappear by 
absorption. 

Lipoma is softer, more compressible and flatter than a gumma. It is com- 
monly single, located in regions unusual for the syphilide, and may remain 
little changed or slowly enlarging for years. 

Fibromata usually develop in childhood, persist through life without any 
tendency to ulceration. 

All growths suspected of being syphilitic should receive specific treatment 
before resorting to radical operative measures. 

Gummatous ulcers are to be distinguished from epithelioma, varicose ulcers, 
chancroid and lupus vulgaris. 

Epithelioma as compared with the gumma is of much slower development 
before ulceration, frequently remaining unchanged for a long time. It is only 
after ulceration occurs that it may be confounded with the syphilide. It may 
then be distinguished from the latter by its more common occurrence at an 
advanced age as a single lesion and of a painful character. The epitheliomatous 
ulcer has a hard, everted and non-pigmented border, an uneven granular and 
warty base, a scanty offensive secretion which does not form into crusts. 

Varicose ulcers are more often located on the lower third of the leg ; more or 
less varicosis, oedema and eczematous inflammation are common features, while 
syphilitic ulcers occur usually on the middle or upper third of the leg, are often 
surrounded by the sound skin and lack the concomitants of varicose ulceration. 

A chancroidal ulcer may almost exactly resemble an ulcerating gumma. 
The history of slow infiltration and tumor before the ulceration, the absence of 
a history of an acute inflammatory course and glandular involvement would 
clearly distinguish the syphilide. 

The ulcers of lupus have been so closely simulated by syphilitic ulceration 
as to lead to the use of the unwise term, syphilitic lupus. Lupus vulgaris begins, 
as a rule, in early life and, on the face, often remains stationary for months or 
years. It is characterized by the formation of small, soft tubercles, which slowly 
break down, and the disease extends by the development of new tubercles, which 
in time ulcerate. No history or evidences of a precedent syphilis are obtainable 
in such cases. 

In doubtful and suspected cases of cutaneous ulceration as in the same class 



412 SYPHILIDES 

of tumors a short course of anti-syphilitic treatment may be employed to help 
establish the diagnosis. 

The serpiginous syphilide. — Syphilitic ulceration is sometimes character- 
ized by an exaggeration of its natural tendency to spread at the periphery, as 
healing progressively takes place in the centre. Hence the name, "serpiginous 
syphilide," which may occur in two forms, the superficial and deep. The super- 
ficial serpiginous syphilide was briefly described under the impetigoform syphi- 
lide. It originates from a pustule and is usually a lesion of the early period of 
the disease, but prone to assume a chronic protracted course. 

The deep serpiginous syphilide is usually a tertiary lesion and may succeed 
a tubercle, a large pustule or an ulcerating gumma. It is a rare syphilide, 
chronic in its course, sometimes extending over a large area and lasting for 
years. It is most commonly found on the inner surfaces of the upper extremi- 
ties, upon the legs and breast and, though involving the whole skin, rarely gives 
rise to-much pain or soreness. 

Starting from one or more lesions the central portion first undergoes soft- 
ening, ulceration, crusting and repair. The infiltration adjacent to the centre 
in turn ulcerates and becomes covered by the characteristic greenish-black 
crusts. New lesions progressively appear at the periphery as if to feed the 
advancing ulceration, so that, in typical cases, the outer rim of a patch consists 
of a wall of infiltration and just within a furrow of ulceration, enclosing com- 
pletely or partially a more or less cicatrized centre. In exceptional cases the 
process may assume a malignant course, rapidly destroy the skin, subcutaneous 
and even the deeper tissues. 

Diagnosis. — A serpiginous mode of extension is not pathognomonic of 
syphilis, but when due to the latter, could scarcely be mistaken for any other 
diseases except lupus and chancroid. 

Serpiginous lupus begins usually in early life: it is more localized and 
limited, generally confined to the face and extremities, and the lupus nodules 
are smaller, softer and more superficial than those of syphilis; its ulcerations 
are less sharply cut and often intermingled with cicatrices. The lupus crusts 
are of a lighter color, thinner and more adherent than those of serpiginous 
syphilis, and its scars more uneven and often traversed by bands of connective 
tissue. 

Serpiginous chancroid may be nearly always recognized by its history, 
locality, absence of preceding infiltration, its undermined edges, erratic course 
and less abundant secretion, which does not dry into crusts. 

The vegetating syphilide. — Sometimes the advanced lesions of syphilis, 
such as the moist papule, ulcerating pustule, tubercle and gumma, take on a 
papillomatous or warty aspect due to a more or less pronounced overgrowth of 
the papillae. This transformation of the surface of cutaneous sores is not 
peculiar to syphilis, and may occur in scrofida, lupus, yaws, pemphigus, sycosis, 
etc. The process is essentially the same in all and arises from some unknown 
local influence which stimulates papillar}' hyperplasia. The favorite seats of 
the vegetating syphilide are the warm, moist and hairy regions of the body. 



SYPHILIDES ,l;1 

especially the genital, axillary, anal, the scalp and bearded portions of the face, 
and the nasal and labial folds. These growths vary in size, shape and elevation, 
according to the basal lesion and the varying height and volume of the vegeta- 
tions. The secretions from these excrescences dry into thin, yellow crusts. 
They finally disappear by ulceration, or by gangrenous death and separation at 
the base. 

Diagnosis. — When a clear history of syphilis and the development of the 
basal lesion is obtainable the diagnosis is quite clear; in obscure cases it may be 
difficult, particularly from such rare affections as lupus verrucosus, pemphigus 
vegetans and yaws. 

Lupus verrucosus usually develops from an irregularly ulcerated surface 
having a history of origin in early life and limited to the face and extremities. 
The base and border of the lesion is soft and the color of the vegetations livid, 
as compared with the flesh tint of the body of the syphilide and its indurated 
brownish colored border. 

Pemphigus vegetans always originates from bullae and extends by the 
formation of new bullae at the periphery, and by the fusion of neighboring 
patches advances sometimes over a large surface. These diagnostic features, 
the early and profound cachexia and the tendency to a fatal termination would 
soon distinguish it from the syphilide. 

Yaws or framboesia is a tropical disease and much rarer than cutaneous 
syphilis, but its local evolution up to the fungating stage may be very like 
nodular syphilis. It can be distinguished from the vegetating syphilide by its 
limitation to tropical regions, its more common occurrence in children, its 
peculiar raspberry-like vegetations, creamy acid secretion and the absence of all 
contributing signs of syphilis. 

V. The pigmentary syphilides. — The confusion existing regarding this 
form has arisen from the inclusion of secondary pigmentary changes under this 
head. The syphilides in common with some other dermatoses may result in 
temporary or more permanent increase or decrease in normal pigmentation. 
Such changes are a part of the clinical history of these affections. The true 
pigmentary syphilide, on the other hand, is primary in occurrence and inde- 
pendent of other eruptions. It may be due to extravasation of blood coloring 
matter (pigmentary syphilide), or to hemorrhages into the skin (purpuric 
syphilide). Both are very rare. 

The pigmentary syphilide may occur at any time in the secondary period of 
syphilis, most often in the latter half of the first year, but may appear as early 
as the second month or as late as the third year. It may be the only form of 
eruption present or coexist with other lesions. Males are seldom found with 
this syphilide and it is most frequently seen in blonde women in early adult life. 

The seat of the eruption is usually limited to the sides of the nock, but 
sometimes appears on the forehead, face and trunk, and exceptionally it may 
have a wide or general distribution. According to R. W. Taylor there are three 
distinctive objective forms of this syphilide : (1) In spots or patches of various 
sizes. (2) As diffused pigmentation, which after a variable time becomes the 






414 SYPHILIDES 

seat of leucodermatous changes, taking the form of small spots, which gradually 
increase in size, retiform pigmentary syphilide. (3) As an abnormal and 
unequal distribution of pigment, probably without excess in quantity, resulting 
in the interblending of lighter and darker colored spots, known as the marmora- 
ceous pigmentary syphilide, from its resemblance to a form of marble. This 
condition is not common and may be overlooked by reason of its subdued tints. 
The second of these forms is the most common and the last the least common. 

The duration of the pigmentary syphilide averages from three to six months, 
but may exceptionally persist into years. The patches are sometimes slightly 
hypersemic, but this is a very transient state and the surface is not elevated or 
scaly. When they begin to fade lighter spots appear, which in contrast look 
whiter than the normal hue of the skin and have led to the mistaken term of 
syphilitic leucoderma. The appearance of atrophy of pigment in these cases 
is entirely an optical illusion, effected by the return of the skin in spots to its 
normal color, bounded by deeper coloration, which gradually recedes regularly 
or irregularly before advancing involution. Some writers observing these 
involutionary variations of the pigmentary syphilide have been disposed to 
call them special forms of syphilitic achromia, not warranted by a knowledge 
of the whole history of the pigmentation. A peculiarity of pigmentary syphi- 
lide is that it is uninfluenced by so-called specific treatment or external appli- 
cations. 

Diagnosis. — In the formative stage the pigmentary syphilide may be con- 
fused with chloasma or tinea versicolor. Chloasma is most often situated on 
the face, where the syphilide seldom occurs, its favorite seat being the sides 
of the neck. Other evidences of syphilis may be present or subsequently appear. 
Tinea versicolor can be distinguished from the syphilitic stain bj' its different 
location, in large patches on the trunk, though it may extend to the neck ; by 
the ease with which the color can be scraped or rubbed off with the epidermic 
scales, and by the presence of its fungus element on microscopic examination 
of the scales. 

In the stage of decline, when lighter spots begin to appear, the s}-philide 
may be mistaken for leucoderma. Location elsewhere than on the neck, and 
a narrow border of deeper pigmentation around the white spots, which charac- 
terizes the latter and is never found in the syphilide, will serve to distinguish 
one from the other. 

. From the hypertrophy and atrophy of pigmentation of the other syphilides, 
the true pigmentary form may be always known by the history of its inde- 
pendent development. 

The purpuric syphilide occupies a doubtful place in the classification of 
syphilitic eruptions, because hemorrhage into the skin in syphilis independently 
of other lesions is exceedingly rare in the acquired form. Hemorrhage may 
occur with any of the early or late eruptions, but is more commonly associated 
with the macular or papular syphilide. The etiology of such effusions of blood 
relates probably more to the pathology of purpura than syphilis. With the 
macular syphilide, purpuric spots, from a pin's point to a millet seed, may 




Fig. 113.— PURPURIC SYPHILIDE 



ASSOCIATED WITH THE PAPULAR VARIETY 

Patient is a man about thirty years of age. At the acme of the secondary 
papular eruption purpuric macular lesions appeared in several crops at the same 
sites, but of wider extent. They are generalized, of a dark purplish color, the stains 
therefrom persistent and apparently little influenced by anti-syphilitic treatment. 




Fig. 114.— TERTIARY SYPHILIDE 



DEEP SERPIGINOUS VARIETY OF THE THIGH AND BUTTOCK 

Patient is a woman of thirty-four who denies ever having had any signs of 
specific infection (ignored syphilis), or previous cutaneous disease. Nearly four 
years ago a lump appeared on upper part of right thigh; weeks later it softened and 
opened on the surface. As this healed like lesions formed successively, some uniting 
in the stage of ulceration, following the same slow course for two years. When about 
healed the contiguous skin of the buttock became infiltrated; two roundish ulcers 
finally formed with sharply defined edges. The inner and upper borders have since 
slowly advanced, while cicatrization followed from the older part. The cut shows 
lesion free from crusts and improving under treatment. 



SYPHILITIC ALOPECIA— SYPHILITIC NAIL AFFECTIONS 415 

appear more or less generally distributed with the roseola, each lesion sur- 
rounded by the flush of the latter. When hemorrhage complicates the papular 
form it may surround the papule or occur in its substance. 

The same factors which produce non-specific purpura together with the 
altered blood of the syphilitic probably explain its occasional occurrence in the 
latter. It is a more frequent complication in children who are the victims of 
hereditary syphilis. 

The presence of a syphilitic eruption in these cases will serve to distinguish 
them from all other purpuric lesions. 

Syphilitic Alopecia 

Loss of hair from syphilis may be more or less general in the secondary 
period, due probably to the changed condition of the blood and consequent 
deficient nutrition of the hair. This early loss of hair may occur in the third 
month or later, and usually consists of a general though irregular thinning of 
the hair on the head; thinning or knotching of the eyebrows, eyelashes, 
mustache and beard may occur, and sometimes the hair falls from the pubic 
and axillary regions. The loss of hair may be very moderate or considerable, 
and in aggravated cases may he nearly or quite complete over the whole body. 
Occasionally the hair falls out in patches resembling alopecia areata, or at 
the site of lesions involving the follicles. Early alopecia from syphilis may be 
aggravated by a coexisting seborrhcea and tend to be more persistent. Usually 
the loss of hair is temporary and is restored spontaneously or by specific treat- 
ment within six months. In the tertiary period localized permanent baldness 
may result from destructive lesions, whether they end in absorption or 
ulceration. The remaining hair in cases of advanced syphilis is apt to be dry 
and harsh. 

Diagnosis. — The irregular and incomplete nature of the alopecia is 
diagnostic of the early syphilitic variety. The knotched eyebrow is always 
suggestive of syphilis, and is said to be more common in women. The more 
distinct patchy variety may be distinguished from the round or oval patches 
of alopecia areata by their irregular shape, tendency to be symmetrical and the 
presence of other signs of syphilis. 

The localized and permanent forms of alopecia due to the destructive lesions 
of late syphilis may be differentiated from circumscribed baldness due to 
lupus, favus, chronic eczema, etc., by the clinical history and the quality of the 
cicatrices. 

Syphilitic Nail Affections 

The nails may be attacked by the syphilitic process in two ways ; one begin- 
ning in the nails constitutes a form of onychia and is chronic in course; the 
other beginning in the neighboring parts extends to the nails, perionychia, 
and may be acute or chronic in course. 



41(5 SYPHILITIC LESIONS OF THE MUCOUS SURFACES 

These inflammations of the nails may differ little from those caused by 
chronic psoriasis or eczema, and may lead to similar atrophic or hypertrophic 
changes, for a description of which the reader is referred to the section on 
diseases of the nails. They occur generally within the secondary limits of 
syphilis, but may appear later. One nail only may be attacked or several at 
the same time, or more often successively. Onychia more commonly affects 
the nails of the hands and runs a mild course. Perionychia attacks the fingers 
and toes about equally, but those exposed to injury from use or accident are 
the most liable. It maj 1, be acute in process and chronic in course, and in the 
ulcerative form may destroy more or less completely the matrix and other 
parts of the nails. When the ulceration is confined to the sides or the free part 
of the nail a regrowth of a perfect nail may be expected, and even prolonged 
ulceration of the base may not prevent the regeneration of a fairly good nail. 
Considerable pain and annoyance may attend ulcerative perionychia, and the 
outcome is always uncertain ; non-ulcerative forms may give little trouble and 
are easily cured. 

Diagnosis. — A mild syphilitic affection of the nails can sometimes be dis- 
tinguished from the non-syphilitic only by a history or signs of syphilis, and 
which can be obtained nearly always in sufficient degree to exclude eczema and 
psoriasis. Ulcerative perionychia of the finger nail may be mistaken for a 
chancre. The absence of secondary manifestation of syphilis at the beginning 
of the nail lesion and the presence of enlarged axillary or epitrochlear glands 
would favor the latter. Simple perionychia occurring in the cachectic may 
be confused with the syphilitic form. In the absence of all other signs of 
syphilis the latter may be excluded after a reasonable delay. 



Syphilitic Lesions of the Mucous Surfaces 

Secondary manifestations of syphilis often occur on the mucous membranes 
coincidently with essentially the same lesions on the skin. Difference in 
structure and surface conditions produce a different appearance however on 
the mucous surfaces, least shown in comparison with the so-called mucous 
patches and condylomata lata of the warm and moist regions of the skin. The 
mucous lesions are chiefly due to congestion and hyperplastic chancres. 

Patches of diffused but well-defined erythema commonly appear on some 
of the mucous outlets of the body in the second month after infection. They 
are most frequently seen upon the fauces, soft palate, pharynx and genital 
organs. Unless they give rise to soreness or are subject to some form of irrita- 
tion they may be easily overlooked. Occasionally the erythema occurs in cir- 
cumscribed spots very like roseola of the skin. With syphilitic erythema of 
the throat the tongue may become hyperaemic generally or in rounded spots 
scattered over its surface. When the hyperemia is intense enough exudation 
occurs in small or large spots, which become grayish-white in color uniformly 
or at their irregular borders, and when the epithelium separates and is thrown 



SYPHILITIC LESIONS OF THE MUCOUS SURFACES 1 1 I 

off there may be left smooth, eroded or superficially ulcerated spots or patches. 
These may be found on any part of the buccal mucous membrane, throat 
and on the lips. They also occur in the nose, on the mucous surfaces of the 
genitals in both sexes and less commonly in the larynx. Mucous patches thus 
formed quite commonly on the tip and sides of the tongue may be annoying 
and painful, especially if irritated. Combined with the effects of hyperaemia 
the dorsum and sides of the tongue may become irregularly fissured. More 
or less hyperplasia may also occur in plaques, which have been variously 
termed leukoplakia, psoriasis and ichthyosis of the tongue. These lesions are 
obstinate in their course. 

Mucous patches vary in appearance with their location, the use or abuse to 
which the parts are subject, and the vital resistance of the tissues. Not arising 
usually from papules there is less hyperplasia than in the condylomata lata of 
the skin and an absence of the elevation of the latter. Occasionally deep ulcers 
or sloughing of the tonsils may be seen. 

Tertiary ulcerations are most likely to attack the gums, soft and hard palate. 
On the gums the process is apt to assume a serpiginous form, gradually extend- 
ing along the line of the teeth. On the soft palate deep ulcers may develop and 
cause an irreparable destruction of tissue if not arrested by timely treatment. 
The power of replacement and repair in the tissues under medication, however, 
even when a large amount of tissue has been eaten away and perforation has 
not occurred, is remarkable. When the hard palate is invaded the bone may 
become involved and necrosed. Tertiary lesions of the mucous membranes 
rarely begin before the fourth year, but may occur thereafter up to a late period. 
Diagnosis. — Syphilitic erythema and mucous patches are not generally 
in themselves sufficiently characteristic to be diagnostic except in association 
with other evidences of the disease. A bluish-red color of the erythema and 
a whiter line of sodden epithelium at the border of a mucous patch are sus- 
picious signs of their syphilitic nature. Karely the origin of a mucous patch or 
ulcer from a papular formation can be determined, and is then in favor of 
syphilis. The lesions of the latter are also free from the sensitiveness and 
signs of inflammation at the border of the non-specific mucous sore unless made 
so by irritation; but mucous plaques often simulate objectively the common 
"canker sores" or apthous ulcers so closely as to make differentiation impossible 
without the presence of concomitant symptoms. Such symptoms are nearly 
always present or soon appear. Owing to the contagiousness of mucous patches 
due to syphilis, in doubtful cases the same precautions should be taken as in 
unmistakable syphilis until the latter can be excluded. 



418 HEREDITARY SYPHILIS 

HEREDITARY SYPHILIS 

(Congenital syphilis; infantile syphilis.) 

Syphilis may be transmitted to the second and, rarely, to the third genera- 
tion, and exhibit many features in common with the acquired disease. There 
is, of course, no initial lesion, but, like the acquired form, the early lesions tend 
to be more generalized and symmetrical than those which appear later. Vesicu- 
lar and bullous eruptions are quite common in hereditary syphilis as they are 
rare in the acquired disease. The mortality from transmitted syphilis is high, 
more than one-half die in utero or within six months after birth. In viable 
infants the disease appears most frequently in the latter half of the first month, 
but-may develop with a rapidly lessening ratio in the succeeding months of the 
first year. It is rare, however, after the third month, and the prospects of 
recovery increase the later the period of development. Each succeeding child 
of syphilitic parents is less likely to be affected by the disease. Whether the 
disease may be transmitted by one parent alone, the other remaining unaffected, 
need not be entered into here further than to say that a woman may have 
syphilis without outward symptoms at all, or until years later, but as to her 
actual immunity in some cases while carrying a syphilitic child nothing positive 
can be said. 

The general symptoms manifested by a syphilitic infant vary with the 
effects of the disease on various organs or tissues ; most often such symptoms 
as pyrexia, pallor, peevishness, first appear, followed by more local disturbances 
of the mucous membranes of the nose, throat, larynx and mouth, of which 
inflammation of the lining of the nose or "snuffles" is the most common. In 
some cases, the liver, spleen, eyes and bones may be attacked. 

Lesions of the skin may precede the catarrhal symptoms, but usually they 
soon follow the latter and in a short time the subcutaneous fat is absorbed, 
the skin becomes loose and wrinkled, and the face sallow and careworn as from 
worry and age. Added to these surface changes may be the stains of early 
eruptions and later lesions undergoing evolution or involution. For the many 
conditions and multitudinous symptoms of congenital syphilis the reader is 
referred to special articles on the subject. The purpose here is only to mention 
briefly the surface eruptions or syphilides of the hereditary form. These occur 
chiefly in the earlier period of congenital syphilis, and are generally of little 
importance in the advanced stage when lesions of the deeper tissues are apt to 
develop, perhaps independently of any cutaneous eruption. 

Erythematous, papular, vesicular, bullous, pustular and nodular types of 
skin lesions are seen. 

The erythematous or roseola syphilide is not common in infants. Like 
most other forms of cutaneous syphilis in infants it most often appears on the 
buttocks and about the anus. The lesions vary in size, are not always defined 
and may coalesce to form large areas of distinct coppery or yellowish-red skin. 



HEREDITARY SYPHILIS 411* 

Sometimes the eruption extends down the inner part of the thighs, up the hack, 
and in rare instances becomes general, even spreading to the soles of the feci. 

There is likely to he more or less desquamation on the dry parts, exfoliation 
of the surface of the soles, and on the buttocks subject to moisture separation 
of the macerated scales may leave the surface raw or glazed. A Less common 
form of erythema has been observed in syphilitic infants, often in association 
with ulcerating lesions of the mucous surfaces of the mouth. The eruption 
occurs in irregular bright to coppery red patches of a half inch or more in 
diameter and is most abundant on the abdomen, lower portion of the chest and 
inner region of the legs. Desquamation maj be moderate or partial. 

As a rule, the more extensive the erythema the less likely is the child to 
recover. In two cases of still-birth and one infant who survived a week, seen 
by the author, the eruption was generalized. 

Diagnosis. — This syphilide may be mistaken for the macular lesions of 
the eruptive fevers. Its localization about the buttocks in most cases, elevation 
above the surface, tendency to coalesce, usually well-defined margins and early 
desquamation, will, in the absence of the characteristic symptoms of the exan- 
themata serve to distinguish it. Other evidences of congenital syphilis may 
also be present. 

This syphilide has been mistaken for intertrigo, to which a syphilitic infant 
is quite liable, however. In the non-specific intertrigo of infants the redness 
does not usually occur in patches or extend beyond the surface exposed to the 
irritation from urine and faeces, and, as a rule, yields readily to simple measures 
of treatment. Absences of these differences and the presence of other signs of 
syphilis ought to make the exclusion of erythema intertrigo easy. 

The papular form of syphilide may occur in hereditary cases in small size, 
large papulo-squamous and in moist papular types of eruption. 

The small papule may appear in conical, acuminate or flat shape. The 
two first are the most common, and may be distributed irregularly over a small 
or large surface, chiefly on the legs, and occasionally in groups of six or less. 
These lesions may be tipped with a scale, sometimes with a small pustule and 
rarely with a vesicle. 

The flat papule may be round or angular; it is often situated in groups, 
slightly raised, smooth, glistening and of a dull red color. 

Papulo-squamous lesions are more common than the preceding, and occur 
in slightly raised elevations, varying in size up to a half inch in diameter. When 
seen early they are found to be reddish-brown in color, but later fade to a 
yellowish-brown hue. The surfaces of the papules are covered with thin scales ; 
they may remain discrete and unchanged in shape during their evolution and 
decline, or rarely circinate, crescentic or figurate forms may develop very much 
like those seen in acquired syphilis. Patches of this eruption may be widely 
distributed or confined to the buttocks, limbs, face or forehead. If exposed to 
much irritation some lesions may ulcerate. 

Moist papules are the most common of the papular form, even more frequent 
in relative occurrence and numerous in points of distribution than the same 



420 HEREDITARY SYPHILIS 

lesion in the acquired disease. They are most often seen at the anus and the 
corners of the mouth, but may develop on any warm and moist region of the 
skin and mucous membranes, and are not unusual alone as a recurring eruption 
over a period of several years. At the folds of the skin and outlets of the body 
moist papules may become fissured. The more superficial, erythematous or 
scaly lesions may be subject to a like complication and become to a certain 
extent moist in character. 

Diagnosis. — Little difficulty will be experienced in recognizing papular 
eruptions of hereditary syphilis by the presence of concomitant symptoms of 
the disease, such as emaciation, snuffles, lesions of the mucous membrane, etc. 
Eruptions occurring in children who are cachectic from other causes are to be 
excluded. 

Primary vesicular eruptions are very rare in hereditary as they are in 
acquired syphilis, and when observed they very often develop into bullae. As 
has been stated in speaking of small papules, vesicles may sometimes cap the 
later lesions. 

Bullous eruptions on the other hand are more common in hereditary than 
in acquired syphilis. They are always an indication of marked severity of 
the disease, and when the contents of the blebs are purulent the termination is 
nearly always fatal. 

Bullous eruptions are often present at birth or appear in the first ten days 
of life in such cases, and may be tense or flaccid according to the quantity of 
serum, pus or blood held in them. Their sites of predilection are the palms, 
soles, nail bed and the lower part of face ; other parts may be invaded in severe 
or exceptional cases, but often the palms and soles only are affected. Around 
the lesions a dark red areola is seen, and when they rupture or dry up, light 
to dark green crusts form which cover an extending ulcer. When the nail bed 
is the seat of a syphilitic bleb the nail often turns black and is finally cast off ; 
in milder cases it may be only distorted in shape, especially at the free border. 

The diagnosis from pemphigus and other non-specific bullous eruptions 
is generally easy ; the early occurrence, situation on the palms and soles, char- 
acter of the bullae, dark red areola and the history or presence of other signs 
of the disease will suffice to distinguish its nature even when the eruption 
appears later than common or in unusual locations. Outbreaks of pemphigoid 
eruptions in institutions described elsewhere can be distinguished by their 
endemic type. 

Pustular lesions in hereditary syphilis are less rare than the vesicular, but 
are not common. Aside from the small pustules which sometimes form at 
the apex of papules their presence is always indicative of cachexia. They are 
associated commonly with other lesions of the disease, and may occur early or 
late in infancy; they may develop into ecthymatous sores with ulcerating and 
spreading bases or be very superficial. Eupial crusts are very rare, while core- 
less, furuncular-like lesions have been observed in a few cases. Occasionally 
the discharge from such pustular lesions becomes locally inoculable and im- 
petigo contagiosa may complicate and multiply the surface conditions. The 



ETIOLOGY OF THE BYPHILIDE8 421 

purely syphilitic pustular lesions are seldom numerous and their recognition 
is not difficult owing to the invariable presence of other signs of the i ! 

Nodular formations may develop in late hereditary syphilis and arc almost 
the only cutaneous lesions of hereditary syphilis in adult life. They are not 
so extensive as in the acquired disease, but otherwise are like the Latter in 
appearance, evolution and involution, and need no separate description here. 

These late manifestations of hereditary syphilis are seldom seen and can 
be diagnosed with certainty only by the presence of other signs of the disease, 
past or present, in the skin, mucous membrane, eyes, teeth or deeper structures. 

Etiology and Pathology of the Syphilides. — Primary syphilis is 
always due to infection directly or indirectly from some person suffering with 
the active disease, and is at the onset a purely local process analogous in many 
respects to diphtheria, tuberculosis, glanders and leprosy, or diseases in the 
lesions of which micro-organisms have been proved to be constantly present. 
In other ways the likeness, especially in the existence of a period of incubation, 
the outbreak of cutaneous efflorescence, and a certain immunity from other 
attacks, lies with the exanthemata, or diseases, which, though markedly con- 
tagious, have not been shown to be, as yet, of microbic origin. Several investi- 
gators have announced the discovery of micro-organisms in the lesions of 
syphilis, notably Lustgarten, Jullien, De Lisle, Schaudinn, and Schiiller, but 
none have stood the scientific tests of their supposed specific nature, and the 
germ of syphilis which is believed to exist, from the analogy of its mode of 
contagion and pathology to some germ diseases, remains undiscovered. The 
immunity of most animals to syphilis is a material hindrance to scientific re- 
search in this direction. 

In this connection it is interesting to note the recent experiments of 
Metchnikoff, who reports that in the case of fourteen chimpanzees inoculated, 
all contracted syphilis after incubation of from twenty-two to thirty-five days. 
Out of fourteen animals, seven showed secondary phenomena ; but these ani- 
mals are so delicate in our climate that tertiary symptoms have not been ob- 
served. It has been proved that syphilitic virus does not pass through bougies 
which allow the passage of the virus of peripneumonia of cattle. Heated to 
forty-eight degrees, it loses its virulence; it does not lose it when mixed with 
glycerine. The recent researches of Schaudinn would seem to verify the con- 
clusion that syphilis is caused by the spirochaeta pallida of Schaudinn, and is 
pathogenic for the human being, for anthropoids, and for certain varieties of 
the lower order of monkeys. 

"Whatever the virus or element of contagion in syphilis may be, clinical expe- 
rience proves that it exists in the initial lesion, in most if not all of the secondary 
lesions of the disease and in the blood during the early eruptive period. Unlike 
the virus of the eruptive fevers, it adheres closely to the lesions and is only 
communicated to another by intimate contact with the abraded or other solu- 
tion of continuity of the epithelial covering of the tissues of the skin or mucous 
membrane. Such contact occurs in the vast majority of cases in illicit, natural 



4-2-2 ETIOLOGY OF THE SYPHILIDES 

or unnatural sexual indulgences, but many cases of direct infection have taken 
place through the habit of kissing, from bites, through touch of the hands, feet 
or body with syphilitic sores. Thus children have sometimes become infected 
while sleeping with a syphilitic. 

Indirect or mediate infection may occur through the medium of utensils 
used in eating or drinking, through the toilet articles used in common, through 
nursing bottles and other articles employed in the care of children, or even 
through the human nipple of a wet-nurse suckling a syphilitic and a non- 
syphilitic child. In professional work the virus may be communicated through 
instruments used in circumcision, vaccination, dentistry, etc. In many occu- 
pations liability to infection exists from the common use of tools or appliances, 
as in shaving, glass blowing, etc. Washerwomen may be infected from the 
linen of a syphilitic, and in numerous ways in the industrial world the danger 
of contagion while slight is always possible. The etiology of hereditary syphi- 
lis need not be discussed here farther than to say that it may be transmitted 
from either or both parents while subject to the disease in its contagious stage. 

With the development of the syphilides other causal factors, besides a spe- 
cific virus, have no little influence, and account in large degree for their varying 
course. These are not peculiar to syphilis, and may be said to be contributing 
rather than predisposing in their relations. Conditions of constitutional im- 
pairment due to malaria, scrofula, alcoholism, the weakness of infancy and 
old age and often some unknown cause, not made apparent perhaps in any 
marked disturbance of health, contribute to the insidious spread throughout 
the system of the syphilitic virus or the products of specific microbes. The 
symptoms produced by these varying etiological conditions, together with the 
variable potency or attenuation of the syphilitic poison inoculated, give indi- 
viduality to cases of the disease in a considerable degree. If good vigor and 
health exist at the time of infection with virus of moderate virulence, the mani- 
festations of the disease may be slight and little or no cutaneous signs of it 
appear. In rare instances the disease from some controlling cause or causes may 
remain latent without the usual chronological symptoms of the secondary stage, 
and years after develop so-called tertian- lesions of the skin or internal organs. 

On the evolution of some of the syphilides another set of causes, beyond 
the normal differences existent in the skin of different individuals, aud chiefly 
external, may operate to modify their development and course. The presence 
of other diseases of the surface, such as eczema or seborrhoea, may modify or 
aggravate the behavior of some secondary eruptions. Slight injuries of the 
skin may determine the seat of lesions, more especially of the tertiarv forms. 
Lack of cleanliness may contribute to secondary infection with pus cocci or 
other micro-organisms, and many observers now believe that the occasional 
suppuration of syphilitic lesions is essentially due to a mixed infection of 
pyogenic bacteria. 

There is an inclination to attribute the negative or mild character of some 
cases of syphilis to a natural immunity of the individual transmitted (perhaps 
through several generations) from some ancestor subject to the disease. 



PATHOLOGY AND PROGNOSIS OF THE SYPHILID! S 423 

According to Unna some portions of the skin are always immune from the 
invasion of the syphilis germ, which while circulating in the whole skin only 
causes eruptions to appear at limited spots, here again resembling the eruptive 
fevers. In untreated cases the germs may become more vigorous, overcome 
the immunity and the number of eruptions consequently multiply. This 
natural immunity, however, tends to always increase, and finally, even without 
treatment, banishes the secondary eruptions. 

While no definite pathogenic organism has been proved to be the efficient 
cause of syphilis, the histological pathology of its lesions is very like that of 
some other diseases known to be germ affections and grouped with it in a 
pathological sense as infective granulomata. 

There is nothing distinctive, however, in the hyperaemia of the macular 
syphilide except the temporary enlargement of the superficial and deeper 
capillaries and a staining of the comparatively few exudation cells in the 
congested area. 

The dense circumscribed cellular infiltration which characterizes tlte syph- 
ilitic papule represents in its beginning and type all other lesions. A larger 
and deeper infiltration originates the tubercle, and a beginning in the sub- 
cutaneous tissue usually denotes the gumma. Variations in extent and in- 
tensity of the process, secondary changes and infections produce the various 
clinical forms of these eruptions. 

How long some of the exudation products of syphilis may remain in the 
tissues after the clinical symptoms subside is uncertain. Neumann has placed 
it at four to eight months, and Unna recognizes in the histological remains of 
cells in the tissues after all syphilides an "explanation of the long immunity 
against infection as well as the points of development of all tertiary growths." 
Hutchinson had before affirmed practically the same doctrine of the origin of 
the later syphilides from the residues of early lesions. Unna believes this 
rejuvenation may take place even from the remains of primary products. If 
this be true it is easy to see how tertiary syphilides may sometimes occur 
without the intervening eruptions of the secondary period. It is believed 
that these cellular elements may remain for a long time about the walls of 
the vessels and glandular structures inactive until stimulated by some internal 
or external irritant. 

The pathology of the multiple forms of the syphilides due to secondary 
changes and mixed infections calls for no special discussion. They give objec- 
tive character to the lesions, but do not change their essential nature. The 
retrograde process in all syphilitic deposits begins in the oldest parts, usually in 
the centre. If these lesions are deeply situated the fibrous framework of the 
infiltrated area is generally atrophied or destroyed with the syphilitic deposit 
and a scar results. 

Prognosis of the Syphilides. — The probabilities of a speedy and com- 
plete cure of the cutaneous lesions of syphilis rest on several more or less deter- 
mining factors. The potency of the specific poison may be so weak as to cause 
only moderate systemic infection and little or no cutaneous efflorescence ; 



424 TREATMENT OF SYPHILIS 

the vigor of the inoculated may be such as to resist the syphilitic invasion in 
a large degree, or a more than usual immunity may be transmitted from some 
progenitor. An abundant eruption would indicate an absence of protecting 
influences. In general it may be said, that in proportion to the number and 
size of the lesions and their tendency to suppurate, together with the relative 
degree of constitutional disturbance, is the severity of the disease and the 
chances of its being controlled early in its course. Much also depends on the 
continuance of appropriate treatment. At the same time it must be borne 
in mind that secondary syphilides are usually benign and self -limited in dura- 
tion. In the tertiary period the earlier the recognition of the lesions and the 
institution of specific treatment, the more favorable the prognosis. 

Treatment of Syphilis. — A want of knowledge or a mistaken sentiment 
regarding syphilis seems to stand in the way of the enactment of public meas- 
ures of prevention. This is remarkable in view of the number of innocent 
victimg_of the disease and the dire effects which may follow in time the mildest 
primary manifestations. Syphilis should be classed with other contagious 
diseases, and systematic protective regulations enforced for the benefit of the 
people. Prevention at present rests in the hands of the individual practitioner, 
who can only advise and insist that his patient must take proper means to 
prevent the infection of others. 

Primary syphilis like other diseases should be treated on the indications 
afforded by each case. Both general and local hygiene should be enforced to 
increase the resisting power of the tissues against the insidious invasion of the 
disease. For the same purpose a constitutional remedy (often a tissue salt) 
should be given if needed, but so-called specifics should not be given in this 
stage unless the disease tends to assume a precocious or malignant type, or the 
primary lesion is so situated as to be likely to destroy the function of or dis- 
figure the part. Strict cleanliness with antiseptic protective dressings should 
dominate the local treatment of the primary sore when possible. 

The unbroken lesions of the secondary period require no local treatment 
other than systematic cleanliness. For pustular eruptions and moist papules 
the use of boric acid or sublimate soap is advisable for local or general bathing. 
Ulcers resulting from pustular lesions may be induced to heal more rapidly by 
washing them with a 1 to 2,000 corrosive sublimate solution, and dusting them 
over with finely powdered boric acid, aristol or nosophen, and when practicable 
they can be covered with gauze and a bandage. Larger or deeper ulcers of the 
late secondary or tertiary period should be cleansed daily or oftener. brushed 
over with the bichloride solution and dressed with some mild antiseptic oint- 
ment. A drachm of boric acid or aristol to an ounce of fresh lard is suitable 
for this purpose. When the suppurative process of mixed infection is active, 
washing the parts with a solution of peroxide of hydrogen is preferable to the 
bichloride, and when there is a tendency to much or progressive infiltration 
a mild mercurial ointment may be employed in dressing the sores. 

Syphilitic lesions of the face or other exposed parts which give rise to 
mental annoyance and suffering may be stimulated to resolve by rubbing into 



TREATMENT OF SYPHILIS '-■' 

them nightly a two to ten per cent, ointment of ammoniatcd mercury. If not 
too extensive they can be treated and protected by being brushed over occa- 
sionally for a few days with a two per cent, salicylic collodion. Nodular infiltra- 
tions when situated in exposed or awkward positions may be gently rubbed 
once or twice a day with a two to ten per cent, oleate of mercury ointment. The 
same application can be employed for the large and sometimes painful syphi- 
lides of the palms and soles, but when there is much thickening of the epidermis 
this must be first thinned with a few days' application of Unna's salicylic acid 
plaster. 

In syphilitic affections of the nails the parts should be soaked and fre- 
quently cleansed with hot b orated water or a hot solution of 1 to 2,000 
bichloride, dressed with mercurial ointment and covered with rubber or other 
protecting fingerlets. If hypertrophic granulations spring up they may be 
dusted with calomel, iodol or iodoform. 

Alopecia due to syphilis may be somewhat lessened by keeping the hair cut 
short, the surface clean and rubbing in lightly at night an ointment of ten 
grains of ammoniated mercury to an ounce of cold cream. 

Mucous patches or deeper ulcerations of the mouth and other outlets of the 
body should be kept clean by careful use of sprays or washes of 1 to 4,000 
corrosive sublimate solution. Calomel powder may be applied lightly to the 
surface of destructive ulcers with a cotton holder or by means of a glass tube 
always attached to a powder blower. Tobacco or alcohol should not be used 
in secondary syphilis, particularly when any lesions of the mouth exist. Then 
it will seldom be necessary to cauterize these lesions with nitrate of silver or 
the stronger acid nitrate of mercury as sometimes advised. Much the same 
local measures can be employed for condylomata lata as for mucous patches. 
Peroxide of hydrogen is sometimes preferable as a cleansing wash, and the 
surface of the lesions should be well dried before the calomel is dusted on. 
If the patches are exposed to friction from opposing surfaces they should be 
covered with layers of antiseptic gauze or some convenient protecting dressing. 

With the appearance of the secondary symptoms or syphilides active inter- 
nal treatment is to be instituted. The relation of the action of mercury and 
its salts to the syphilitic processes cannot be discussed here. That it is not 
a perfect similium is well known, but it is the best we have, particularly in its 
range of action on the skin and mucous membranes. While a similarity can 
be traced in the anaemia, glandular enlargement and nervous disturbances, it 
is especially the proneness to suppurative and ulcerative destruction of the 
surface tissues in the action of mercury which points to its applicability in 
the treatment of the syphilides, because in them it is this tendency we most 
desire to prevent and combat and over which it often ' exhibits a magical 
influence. A mercurial should always be given with the beginning of the 
secondary symptoms or eruptions in pretty full and frequent doses of the lower 
decimal attenuations, but never to the extent of producing salivation, or for 
an unlimited time. Every few weeks it should be omitted and any other 
indicated remedy administered in the interim of days or weeks, according 



426 TREATMENT OF SYPHILIS 

to the urgency of the case, until again resumed. This alternating treatment 
with mercury should be carried through a period of three to four years, with 
a gradual lessening of the dose and lengthening of intervals in the latter half 
of the course. 

Choice of a mercurial may depend on the general symptoms as well as 
the character of the eruption. When the first eruption is purely macular and 
attended with mild symptoms I prefer mere. sol. lx, in one grain doses. If 
the mucous membranes are attacked out of proportion to the skin eruption 
mere. dulc. is to be preferred in the same attenuation and doses. These two 
mercurials are well adapted to the maculo-papular form of syphilide or to the 
small miliary-papular when there has been slight constitutional disturbance. 
With the onset of the generalized papular eruption particularly if the first to 
appear and the constitutional symptoms are pronounced, mere. cor. in the 2x 
or 3x trituration usually fits the case best. Even in the pustulo-ulcerative 
forms-ef secondary syphilide this mercurial is often indicated, particularly if 
the lesions are persistent, with a purplish areola, a tendency to become hemor- 
rhagic and form black crusts. But when there is an early outbreak of the 
smaller pustular lesions (acneform, variolaform, etc.) or the development 
of larger pustular forms later in the secondary stage the combined action of 
mercury and iodine often cover the case better, both in relation to the general 
symptoms and the local conditions. The anasmia diminishes more rapidly 
under the iodide of mercury than from any other of its combinations. When 
the totality is more like mercury the protoiodide can be administered in the 
lx trituration ; and when a stronger resemblance to iodine exists the bin-iodide 
is to be preferred, beginning with two or three one grain tablets of the 2x, and 
later increasing the dose if necessary or substituting the lx in place of the 
former. The oisulphuret of mercury (cinnabar) is a mild mercurial which 
may be occasionally indicated when moist papules and condylomata form or 
when sulphur symptoms are prominent; it can always be given in the lowest 
trituration. The one grain tablet decimal triturates of the various mercurials 
are most convenient for use, giving exact dosage and making a gradual increase 
easy by adding a tablet to one or more of the daily doses. A gradual decrease 
can be effected in a like inverse order. The intervals between doses may vary 
from two to six hours, according to the needs of each case. 

Occasionally severe destructive or persistent cases of secondary syphilis 
are seen which seem to call for a more rapid introduction of mercury into the 
system than is practicable by the mouth. In such cases the mercurial may be 
given by inunction, fumigation or by hypodermic injection. 

Inunction consists in rubbing into a portion of the skin, selected and pre- 
pared for the purpose, twenty to sixty grains of a twenty-five to fifty per cent, 
mercurial ointment made with fresh lard. Taylor divides the surface of the 
body into eleven regions for the purpose of giving that number of inunctions. 
These are: 1. The neck and head. 2. The right axilla, arm, forearm and 
hand. 3. The left axilla, arm, forearm and hand. 4. Eight half of chest 
and abdomen. 5. Left half of chest and abdomen. 6. Right half of back. 




TREATMENT OF SYPHILIS 427 

7. Left halt* of back. 8. Right thigh and groin, i). Left thigh and groin. 
10. Right leg and foot. 11. Left leg and foot. It is not important to in- 
clude the head, neck or hands, hut if inunctions are made in these exposed 
regions a white precipitate or calomel ointment may be substituted lor the 
ordinary mercurial. Before an inunction the portion of the surface to he 
rubbed should be scrubbed with a lather of soap, washed oil' with hot water, 
dried and then wiped over with alcohol. If the operator's hands are sound he 
need only protect them with an application of oil or soap before, and thoroughly 
wash them at the end of the rubbing; if abrasions or cracks exist rabbet gloves 
may be worn. About half an hour is required to make a satisfactory inunc- 
tion,, and it is usually repeated every second night, until a course of six to 
eleven have been given. Then, after a few days' interval, another course may 
be started if needed, or other methods of treatment substituted. The patient 
should always be examined before each inunction and if any tendency to saliva- 
tion appear the treatment should be suspended for a suitable time. It is 
generally better to wash off the remains of one application just before another 
is made in a different region, thus keeping only one area anointed at one time. 
It is probable that the absorption of mercury by the skin is effected chiefly 
through the glands and that it enters the circulation in a modified form. 

Fumigations with mercurial vapor are occasionally used, especially for 
persistent and localized eruptions and for short periods of treatment. They 
are given in the same manner as the domestic hot air bath. The patient, after 
thoroughly washing the skin, is seated naked on a cane-bottom chair, blankets 
thrown about him and a special vaporizing lamp containing thirty grains of 
calomel or forty grains of cinnabar is lighted and placed underneath the chair. 
Very soon free perspiration begins; in fifteen to twenty minutes the drugs are 
entirely evaporated. The lamp is then removed and after the patient is cooled 
off a little he retires to bed with the same blankets wrapped about him. On the 
following day the patient should be warmly clad, wearing flannels next to the 
skin, and take care not to get chilled. The bath can be repeated two or three 
times a week according to the effect desired or obtained, but it should rarely be 
employed for more than four weeks and should be discontinued at any time if 
it produces any ill effects. It is not adapted to very debilitated subjects. 

Hypodermic injections of mercury are only called for when for some reason 
the drug cannot be given in the other ways named or when a speedy effect is 
desired. Probably this method is more often employed for syphilis of other 
organs than for the skin, and few patients will submit to it under ordinary con- 
ditions. The objections to mercurial injections are the soreness they produce, 
often nodular swellings and sometimes abscess. A solution of one-tenth to one- 
fortieth of a grain of mere. cor. in ten drops of distilled water is generally used. 
no other solution having been found to possess more uniform merits. A hard 
rubber syringe (preferably holding only ten to twelve drops) with a strong steel 
needle is used and under strict antiseptic precautions. The gluteal region is 
selected as best suited for this medication, the skin made aseptic, the needle 
inserted deeply in the tissues and slowly emptied. Gentle rubbing over the 



428 TREATMENT OF SYPHILIS 

injected part after the needle is withdrawn helps to diffuse the solution and 
probably diminishes the after pain and liability to abscess. Hypodermic injec- 
tions may be repeated every day or two and the dose lowered or increased accord- 
ing to the susceptibility of the patient and the results obtained. Intravenous 
injections of mercury have not proven satisfactory or superior to the method 
just mentioned. 

In the late secondary syphilides and in the tertiary period when mercury- 
is indicated, the biniodide, all in all, has proved the best mercurial in the 
author's experience. Mercury is then often losing its full control over the 
syphilitic process of infiltration and iodine becomes in a way a more potent 
element. Iodine, however, is never the specific for syphilis that mercury is, 
and needs to be harnessed with another substance to do its best work. Hence 
its value combined with mercury and for certain conditions in union with 
potassium or sodium. Iodide of potassium is especially indicated for the 
denser-and deeper infiltrations in or from syphilis. It may be of service there- 
fore in the secondary period when there is unusual infiltration and swelling 
of the tissues involved, and also when the lesions tend to become hemorrhagic. 
But the action of iodide of potassium is to subdue rather than cure syphilis, 
and in the secondary stage of the disease at least is always to be discontinued 
when it has accomplished its special work. In the tertiary period when there 
is a continuation or revival of cell products from syphilis without contagion, 
the iodide should be given longer to subdue the slower but more dense and per- 
sistent tendency to infiltration of the skin and other tissues. Occasionally 
when important organs are endangered the dose may need to be rapidly in- 
creased to its maximum quantity. Seldom is it necessary to give it in exces- 
sive doses, which do not by any means carry a proportionate effect. The writer 
has seen large subcutaneous gumma disappear under the influence of fifteen 
grains daily of the iodide given in divided doses. In tertiary syphilis mercury 
is still needed to complete a cure, and the biniodide can be administered with 
the iodide of potassium (mixed treatment), or still better, the 2x tablets in 
alternation with the latter. When the more urgent symptoms have subsided 
one drug alone (perhaps in smaller doses) can be given for a few weeks, and 
then the other substituted, and so on by alternate substitution as long as may 
be needed. 

Mercury and the iodide of potassium are not the only remedies for syphilis. 
In nearly all cases a cure may be facilitated by occasionally suspending these 
so-called specifics during a lapse in the activity of the disease and administer- 
ing for a time a more indicated drug. The fact that the better the general 
health is maintained the greater is the relative immunity of the tissues to the 
advances of syphilis not only points to the probable value of individualized 
therapeutics, but experience has proved its utility in the disease. Among drugs 
see indications for Argen. nit., Arsen. iod., Attr. mur., Carbo animal is. Canst.. 
Coni., Condurango, Cup. Ars., Hepar, Kali bichrom.. Lack., Lye. Mez., Nat. 
arsen., N. mur., Nit. acid, Pet., Phos.. Phyto.. Sepia-. Bit., Staph.. Stilhhg., 
Sul. and Thuja. 



LEPROSY 129 

The hereditary syphilides are to be treated on the same principles as the 
acquired eruptions with due allowance for age and delicacy of tissue. If the 
father was syphilitic at the time of conception or the mother be syphilitic dur- 
ing pregnancy the latter should be systematically treated throughout her preg- 
nancy, both for her own and the child's safety. After birth a syphilitic infant 
may be treated still through the mother indirectly, the latter being under treat- 
ment and nursing her child. Often this is impracticable and inadequate, and 
remedies need to be administered to the child direct. Hypodermic medication 
cannot be employed, and inunction or fumigation is seldom practicable for a 
child in the first year of life. Mercurials and other indicated drugs can be 
given usually in the 3x preparations without ill effects, and if the cutaneous 
lesions are severe or persistent a mild ointment, such as fifteen grains of calomel 
to an ounce of fresh lard, may be employed locally. In all cases absolute 
cleanliness of the diseased skin should be maintained, and when a medicated 
ointment is not used the affected skin, especially about the buttocks and 
genitals, should be protected with applications of a bland fat or oil renewed as 
frequently as needed. After the first year of life inunctions may be cautiously 
used if required by the persistency of the disease. For this purpose five to 
twenty grains of a fifty per cent, mercurial ointment may be employed every 
two or three days, according to the age of the child and the intensity of the 
disease. 

Treatment with mercury should always be intermittent, either suspending 
all drug treatment or giving other indicated and reconstructive remedies in the 
interim. The course of treatment should extend over three years or more. 



LEPROSY 

(Elephantiasis Grwcorum; Lepra; Satyriasis; Leontiasis.) 

Definition. — A chronic endemic contagious disease due to a specific 
bacillus, insidious in its development, characterized by the occurrence of 
erythema, anaesthesia, pigmentation, neoplastic growths, atrophies, ulcera- 
tions, and deformities varying with the parts affected, and usually result- 
ing in a profound and fatal cachexia. 

Leprosy probably had its origin before the beginning of historical records 
and is accounted the most ancient of human diseases. In some countries it has 
been endemic for centuries; in other and more enlightened lands it has in 
the course of many years slowly declined and ceased for a time to reappear. 
But it has progressively invaded new countries and to-day has a wide distribu- 
tion, estimated to be twenty-five per cent, of the habitable portion of the earth. 
In this country lepers are colonized or have been found in isolated cases in 
Louisiana, Minnesota, Iowa, Wisconsin. California, Colorado, Oregon, Utah, 
South Carolina, Texas, Florida and New York. Sporadic cases may appear 
in any large city, while it is estimated that the number in the United States 



430 LEPROSY 

is from three to five hundred. Seven cases have been under the care of either 
the author or editor during the past few years, and the former observed in 1902 
the varied manifestations of the disease in ' the Norwegian lepra colonies. 
While the number in New York is not large, it is probable that new cases will 
occasionally appear. Some are to be found in New Brunswick, Canada, but 
the Sandwich Islands afford the most recent illustration of the rapid' develop- 
ment and spread of the disease under some favoring conditions of climate, 
race. etc. 

Symptoms. — The manifestations of leprosy vary with the form and stage 
of the disease. Two principal forms are described, the tubercular, chiefly in- 
volving the skin and mucous membranes, and the anaesthetic, chiefly attacking 
the peripheral nerves. 

These two forms may coexist in the same patient and have been termed 
the mixed form of leprosy. Impey also describes a fourth form due to a mixed 
infection from syphilis and leprosy, and designated by him as syphilitic leprosy. 

The stages of the disease are not well defined, but a period of incubation, of 
prodromata, and of eruptive and degenerative manifestation has been recog- 
nized. 

The stage of incubation is very uncertain as to duration, because there are 
no recognizable initial lesions in the vast majority of cases, and it is probable 
that inoculation does not occur often through the skin. When a person comes 
from a leprous to a non-leprous country without any signs of the disease, and, 
after an interval of health, develops prodromal or eruptive symptoms of leprosy 
it is a logical inference (drawn from a group of such cases) that such interval 
represents some portion of the stage of incubation. Thus,, from observation, it 
has been estimated that this period may vary from a few weeks to years ; even 
as high as ten, twenty and forty years have been given. If a. patient resided 
some years in a leprous country it is manifestly impossible to fix the date of the 
beginning of an incubation ending years later. One of my cases was born in 
South America and came to this country Avhen fourteen. Two years later he 
began to show the first signs of leprosy, and when sent to me for diagnosis a 
year later, or three years after arriving in this country, he exhibited well 
marked macular anaesthetic lesions. Another case, male, age 32, had the his- 
tory of having lived in the West Indies for several years, but returned to this 
country sixteen years before the tubercles of leprosy developed, though during 
the two previous years he had suffered from prodromal symptoms of debility, 
neuralgia, etc. A near relative of this patient who left the West Indies at the 
same time was said to have developed the disease five years before and to have 
lived in seclusion since. It is quite possible, though not evident, that my 
patient may have been inoculated in some way by this relative and that his 
incubation was* much shorter than was apparent from his history alone. 
Another case of advanced disease seen in Norway gave a history of emigration 
to this country when fourteen years of age; developed leprosy at thirty-five 
while living at Chicago, and returned to Norway twelve years ago. 

There must be great differences in the resistance of the tissues of different 




Fig. 115.— LEPROSY 

TUBERCULAR VARIETY 

Patient, a Dane of fifty-eight years. Probable duration of disease, ten years, 
although the prodromal state may have started some years before. Nearly twenty 
years of the patient's life was spent in the West Indies in the proximity of lepers. 
The first lesion appeared as a brown pigmentation on the left knee, then nodular 
elevations appeared on the face, especially involving the eyebrows, lips, chin and 
ears. The skin of the entire face is thickened, dependent portions enlarged and 
colored a dark brown. All areas of pigmentation on the body and arms, as shown 
in the illustration, are raised and thickened. The patient has become blind as a 
result of the disease. Arsenicum iodatum, third decimal, and arsenicum album have 
improved the patient's general condition to a great degree. 







Fig. 116.— LEPROSY 

Posterior view of the subject depicted in Fig. 115, showing the discoloration, 
induration and tumefaction of the skin. 




LEPROSY 481 

individuals to the germs of leprosy as to all other contagions, and these dif- 
ferences are modified in various ways by food, habits, climate, etc. Nearly all 
the cases of prolonged incubation have been in people who removed from a 
leprous region to one in which the disease was not endemic. 

Prodromal symptoms follow the stage of incubation and may vary in dura- 
tion from three months to a year or more. During this period in most cases 
of tubercular leprosy intermittent febrile disturbances occur, often preceded 
by chills and other common features of pyrexia. There may be sensory or 
motor disturbances, drowsiness, depression and general weakness which unfits 
the victim for ordinary duties or work. Epistaxis may occur from the general 
condition in the prodromal period, and, at a later one,, from ulceration of the 
nasal mucous membrane. General or local disorders of the perspiratory func- 
tion are not uncommon either from constitutional weakness or vasomotor dis- 
turbances. Sensory disorders, such as headache and vertigo, are sometimes 
frequent, but tend to become more severe with a nightly aggravation in the 
next or active stage of the disease. Neurotic prodromata, however, are espe- 
cially common in the anaesthetic form of leprosy, but they vary greatly in char- 
acter and intensity and are sometimes so ordinary or mild in nature as to 
escape notice. Numbness was the only sensation experienced in the prodromal 
stage by one of my patients; the location of the sensation afterwards became 
the seat of the lesions. 

In the anaesthetic form abnormalities of sensation may take the form of 
more or less severe itching, formication, tingling, pricking, smarting, burning, 
stiffness, etc. These are not constant, often shifting their location as to sur- 
face and depth. Sometimes the motor nerves are affected and locomotion inter- 
fered with to a considerable degree. 

Leprous eruptions. — The eruptive stage of tubercular leprosy shows first 
on the skin in large or small spots which resemble ordinary erythema ; they may 
be few or many, confined to one region or scattered over the body. The color 
disappears on pressure, and the patches may spontaneously disappear and reap- 
pear several times. The affected skin feels slightly swollen and tense, is some- 
what hypersesthetic and an excessive quantity of sweat is secreted therefrom ; 
with the full development of the macular eruption febrile symptoms, if pres- 
ent,, usually subside. Finally most of the spots fade away and leave no trace 
behind. 

Some of the spots fail to resolve, but become more pigmented and sharply 
marked until they become stationary. In these prominent patches the first 
tubercular infiltrations occur; usually these nodules resemble a split pea in 
size and shape, are of a pinkish or yellowish-brown color and may remain 
stationary or progressively enlarge by fresh deposits of leprous material. 
The deposit is often preceded by fever, and new tubercles generally appear in 
crops. The sites of predilection are the face, ears and extremities, but they 
may appear on any part of the body. According to Impey the first tubercle 
is apt to develop at the inner angle of the eyebrow and causes a thinning of the 
growth of hair. This loss of hair with a thickening of the skin at this point 



432 LEPROSY 

and following prodromal symptoms is diagnostic. Wherever the leprous de- 
posit occurs the skin becomes thickened and elevated into round or flat, sharply 
outlined prominences which, though close together, are often clearly distinct 
from each other. They are of soft consistence, of a yellowish or brownish-red 
color, sometimes reach the size of a walnut or larger, and by aggravation or 
confluence may form large masses or extensive plaques. The deformity result- 
ing from leprosy is generally progressive, especially on the face, which becomes 
hideous and pathognomonic in aspect. 

Leprous infiltrations may go on increasing in size and extent and becoming 
darker in color for three or four years before ulceration occurs. Occasionally 
they undergo absorption, leaving stains or scars to be succeeded by a fresh crop 
in the same or other regions. Sometimes fibrous changes transform them into 
small hard masses, which may persist without change indefinitely or take on 
keloidal growths. 

The ulceration of leprous growths begins with a softening and disintegra- 
tion which goes on until a shallow, indolent ulcer is formed, secreting a mucil- 
aginous liquid, sometimes drying into crusts. These ulcers may heal spon- 
taneously or under treatment, or they may increase in size until they become 
extensive in area and depth ; much tissue may be destroyed in their course even 
down to the tendons and bones. The tributary lymphatic vessels, near and 
distant glands become swollen and painful, and later may suppurate. 

The mucous membranes may become affected early or late in the disease. 
Morrow believes that in a majority of cases leprosy first manifests itself in the 
mucous membranes, pharynx and upper air passages. Impey, on the other 
hand, coincides with the more general view that these parts may commence to 
be affected about four years after the advent of tubercles in the skin, and that 
the parts are attacked in order nearest the surface inwards, viz., the lips, 
tongue, palate, fauces and larynx. The first observer mentions the slight 
husky and rough voice and coryza as among the earliest signs of the disease, 
and Impey says when the throat is affected " the voice, which at first is harsh 
and croaking, soon becomes sibilant and almost inaudible." "When infiltrations 
form in the nose the voice assumes a nasal tone, and much distress, almost suf- 
focation, is sometimes felt from the obstructive growth of tubercles in the air 
passages. Tubercles of the lips soon ulcerate and form painful and persistent 
ulcers ; these and other ulcers of the mouth and nose secrete a fetid discharge 
which mingling with the odor from the cutaneous lesions is said to produce a 
characteristic sweetish smell. 

Leprosy beginning in childhood and youth may cause an arrest in physical 
growth, sexual development and a corresponding deficiency in the production of 
new hair. 

The progressive advances of leprosy may be slow, extending through many 
years, with increasing intensity and suffering until the patient's endurance is 
so far exhausted that he falls an easy victim to some secondary or intercurrent 
affection. A few die directly from obstructive leprous growths in the throat, 
many from asthenia, consequent on the excessive drain from ulcerating sores ; 



LEPROSY 43a 

others from secondary kidney and intestinal disease, while a large number 
succumb to intercurrent attacks of pneumonia, bronchitis, erysipelas, etc. 
One mild case of tubercular leprosy seen by the writer had existed for three 
years without any apparent effect on the general health. 

The eruptive stage of anaesthetic leprosy begins with erythematous or bul- 
lous lesions. The stage of incubation is generally longer than in the tuber- 
cular form, the prodromal symptoms more distinctly, neurotic, and the course 
of the disease less varied. The erythematous spots are very like the primary 
lesions of tubercular leprosy in appearance, but they are not evanescent, rather 
they are less hypersemic,. more pigmented, persistent, and tend later to enlarge 
at the periphery while they clear somewhat in the centre. At first the whole 
lesion may be hyperaesthetic, but subsequently this is limited to the darker and 
advancing periphery while the central portion becomes usually more and more 
anaesthetic. Loss of sensation may sometimes be found in apparently un- 
changed portions of the skin, particularly when supplied in common with the 
leprous macule by a branch of the same nerve. Occasionally hyperemia and 
pigmentation do not occur and the primary visible change in the skin is the 
absorption of its normal pigment. Loss of color may be by gradations, whether 
primary or secondary, and rarely the skin becomes white as in leucoderma. 

The complex sensations of the skin may not be all lost at once ; some fibres 
may be irritated while others are deadened. Thus the tactile sense may be 
preserved for a time after either or both of those of temperature or pain are 
abolished, or vice versa. The disassociation of sensation may go farther even, 
and the sense of heat felt and the sense of cold lost, or the opposite. In a 
more advanced stage all sensory functions of the affected skin are abolished, the 
whole thickness of the skin is affected, secretion from the sweat and sebaceous 
glands diminishes or ceases, the hair turns white or falls out, the surface be- 
comes dry and atrophy of all parts occurs. Blunted sensibility and lowered 
vitality of the skin during this period may result in cutaneous lesions from 
unfelt injuries of various kinds. Indeed, Impey believes the bullous lesions to 
be mentioned are the result of accidents and not directly due to the leprous 
poison, but Morrow says bullae may precede by several months the appearance 
of any macular lesions. 

Bullous eruptions may develop suddenly with or without sensations of 
stinging, formication, etc. They are of a variable size, filled with a clear 
yellowish serum and rupture in a few hours, leaving an excoriated surface 
beneath. Such lesions heal rapidly and leave stains or cicatrices. Slight 
frictions and moderate heat, which would only moderately redden the surface 
of the normal skin, may produce in the leprous blisters or even ulcerations. 

The macules of anaesthetic leprosy may remain discrete or merge together 
and form more or less extensive irregular or gyrate patches, characterized 
usually by sharply defined, slightly elevated reddish margins and paler atrophic 
centres. Exceptionally the skin of the centre of a patch may be partly restored 
to health and then the color may return, even to a darker shade than normal. 
More or less desquamation takes place from the surface of a completely devel- 



434 LEPROSY 

oped patch, and sometimes the skin presents a shiny or glossy appearance,, as 
an effect of the complex atrophy of the parts. 

So long as the disease affects only the sensory nerves it may become quite 
extensive without materially affecting the general health. Suffering from 
neuralgic pains, eruptive and other annoyances may be experienced, or the 
manifestations may be so slight as to awaken no suspicion of their grave nature. 
Occasionally many years may elapse before other nerves, insidiously attacked, 
are disorganized and the terrible results of anaesthetic leprosy appear. This 
later advance of leprosy affects particularly the nerves of the face and extremi- 
ties; the ulnar and peroneal nerves especially seem to be seats of predilection 
for the ravages of the leprous bacillus. Eegular or interrupted thickenings of 
the ulnar nerve up to the size of the little finger may sometimes be felt behind 
the olecranon early in the advance. It is sensitive to touch, and pressure may 
give rise to pain at distant points along its course to the fingers. Other nerves 
of the extremities may undergo similar changes. Later, the enlargements and 
tenderness lessen the progress of degeneration. 

The effects of complex nerve degeneration, such as partial or complete 
paralysis, atrophy and deformity from contractions, may often be seen first in 
the little finger ; the first phalanx becomes forcibly extended while the middle 
and terminal phalanges are flexed towards the palm, constituting, when all the 
fingers are involved, the " leper claw." Atrophy follows paralysis and often 
the abolition of the sensory and trophic functions of the nerves lead to other 
deformities and mutilations. Blebs may appear over the phalangeal joints,, 
ulcerate, expose and destroy the deeper parts ; unf elt injuries of the surface may 
pursue a similar course. Gangrenous changes may cause a spontaneous am- 
putation of the fingers, or absorption of the bone may take place at some point, 
and one after another phalanx lost without ulceration or gangrene. Stumps of 
the fingers of different lengths and pointing in various directions may exagger- 
ate the actual mutilations to the utmost degree. The feet undergo similar muti- 
lation and deep plantar ulcers are not uncommon in those who habitually go 
barefoot. As the disease progresses the muscles of the hand, forearm and 
shoulder may become successively affected. The corresponding muscles of the 
foot and leg are not usually involved to the same extent as the hand and arm. 

The nerves which supply the face may be attacked at an early stage of the 
disease and characteristic deformities result. The first division of the fifth 
cranial nerve and branches of the seventh are usually affected. The patient 
may be unable to close the eyes from paralysis of the orbicularis ; the secretion 
of the lachrymal gland may cease, thus leaving the eye-ball exposed to irrita- 
tions and disease, especially of the cornea ; or if the tear gland is not affected 
the everted lower lid permits the secretion to run down over the cheek. The 
lips and cheeks may be flaccid and drooping from paralysis of the buccal branch 
of the seventh nerve ; if only one side is affected the face is drawn to the opposite 
side. 

The sensory nerves of the throat may be affected so as to interfere with the 
function of deglutition, cause regurgitation through the nose, etc. Impey did 




Fig. 117.— LEPROSY 

MACULAR, ANAESTHETIC VA1UETY 

Patient is a Chinaman of thirty years. Duration of disease, three years. 
Brownish-black macules, generalized, but worse on the back and arms. This sub- 
ject developed true tubercular lesions a year after the above photograph was taken. 




Fig. 118.— LEPROSY 

MIXED TUBERCULAR AND MACULAR ULCERATIVE TYPES 

Patient is a Chinaman of thirty-three years. Lesions are generalized and consist of macules, 
nodules, ulcerations, scars, fissures and crusts. Duration of disease, four years. Tumefaction is 
prominent on the face. Lachesis has caused a pronounced improvement in the patient's general 
condition. 



LEPROSY I-' 

not observe any of these effects, and states that in anaesthetic leprosy he "in- 
variably found the mucous membranes healthy." The victims of anaesthetic 
leprosy succumb to intercurrent diseases, or finally die from the exhausting 
effects of- gastric or intestinal disorders induced by the disease. 

The eruptive manifestations of mixed leprosy include lesions of both the 
tubercular and anaesthetic form; one or the other may predominate. The type 
is apt to be characterized by chronicity and severity, from the presence of new 
growths and the atrophy and destruction of normal tissues and parts. 

Syphilitic leprosy is described briefly by Impey, who claims that syphilis 
and leprosy may coexist and ravage the human tissues at the same time. 
Such cases are characterized by earlier ulcerations of the skin, loss of hair 
in large patches, swollen glands, indolent abscesses, ulcerations of the mouth 
and throat, and necrotic destruction of bones, especially of the nose. To these 
may be added the manifestations of any form of leprosy. 

Duration. — This varies widely. From fairly reliable information and 
observation of a number of cases of each form, excluding those who recovered, 
Impey makes the average duration in years: forty-four cases of tubercular 
leprosy 5.5 years, the shortest duration 1 and the longest 13 years; forty-one 
cases of anaesthetic leprosy about 11.5 years, the shortest 2 and the longest 31 
years; twenty-three cases of mixed leprosy about 9.25 years, the shortest 1 and 
the longest 23 years. 

Inasmuch as the tubercular form prevails most in a new country or among 
a virgin population, and the anaesthetic in greater relative frequency with the 
continued prevalence in after years, it follows that the average duration may 
vary considerably in different countries or regions with the prevailing form 
of the disease. 

Etiology and Pathology. — The efficient cause of leprosy is the bacillus 
lepra discovered by Hansen in 1874. This micro-organism resembles the 
tubercle bacillus closely, but is found in greater numbers in the surface lesions, 
in groups, and is more readily stained than the latter. After some fluid 
expressed from a leprous tubercle has been prepared on a glass slide and 
stained with fuchsin the bacilli may be seen, under a microscope, with a power 
of 300 diameters, as pink rods, in length about one-half the diameter of a 
red blood corpuscle, in width about one-fifth their length. These germs may- 
be always found in the tubercles of leprosy, but are not always found in the 
peripheral nerves involved in the anaesthetic form. Whether it is the bacilli 
or their products which produce the mischief is not known. They have 
been found by some investigators in the liver, spleen, kidneys, lymphatic glands, 
hair follicles and sebaceous glands, but not in the physiological secretions with 
possibly one exception; when the mucous membranes are attacked numerous 
bacilli may be found in the secretions from the affected parts. Males are 
more subject to the disease than females in the proportion of nearly two to one; 
it is rare in children and never occurs in infancy. It is probable that there 
may be several if not many predisposing or contributing factors in the causa- 
tion of leprosy which operate to render the tissues susceptible to its special 



430 LEPROSY 

cause or contagion, as outbreaks of the disease in a new region can always be 
traced to the immigration of lepers. The contributing causes pertain largely 
to the individual, and to conditions which might predispose to other inoculable 
as well as to non-contagious diseases. Excesses of all kinds, bad hygiene, 
insufficient food, etc., may so diminish vital resistance as to render the 
normally immune tissues susceptible to the action of a direct cause. Certain 
influences may be attributed to climate, race and sex, but collective or personal 
habits of living probably underlie these factors. When leprosy has soon gained 
headway among a people there have always been found to exist careless and 
promiscuous ways of living. In some instances the mode of contagion is 
direct and may occur in the act of coitus, kissing, bodily contact while sleep- 
ing or otherwise, especially when abrasions or wounds of the surface exist. 
The poison may be transferred through the medium of eating utensils, toilet 
articles, wearing of clothing previously used by a leper, possibly by insect bites, 
and sometimes from inhalation of the dried secretions floating with other 
dust in the air. 

The pathological changes set up by the presence of bacilli in the tissues 
or by their products (toxines and mucus), are inflammatory in nature, result- 
ing in diffuse granulomatous growths characteristic of the leprous tubercle. 
Its peculiarity consists, according to Unna, " on the one hand, in its limitation 
to the connective tissue elements, and especially to the lymphatic system of the 
skin, and on the other, in the enormous growths of organisms, whose number 
far exceeds anything we are accustomed to find in other infectious diseases." 
It is not the very moderate cellular growth, but the numerous bacilli encapsu- 
lated in their own mucus that gives pathological character to leprous tubercles, 
and, in Unna's words, " to the paucity of the cellular elements and the pre- 
ponderance of the organisms dormant in the bacillary mucus, the remarkable 
indolence and relative benignancy of these growths may be ascribed." 

In anaesthetic leprosy the pathological changes occur in and about the 
peripheral nerves from temporary or more prolonged presence of bacilli or 
from their products, resulting in a form of neuritis and consequent partial or 
complete loss of nerve function. Unna describes an angio-neurotic stage or 
form, and a secondary bacillary embolic nerve leprosy, which may be quite 
independent of the former. The first is characterized by hypertrophic changes 
and a few bacilli; the second by bacillary embolism which gives rise to local 
hypersemia, staining and oedema. If the latter occur in areas previously 
affected by angio-neurotic changes (perhaps unnoticed), thickening takes 
place and permanent cutaneous lesions result. But when the hyperemia and 
pigmented spots of embolic origin are developed in previously sound skin the 
bacilli may at once disappear and the visible cutaneous lesions rapidly and 
completely fade away. These constitute the temporary lesions of macular 
leprosy. 

Diagnosis. — Typical cases of the disease are easily recognized in a leprous 
country or in persons who have lived in such regions. Atypical sporadic cases 
may be difficult to diagnose as the prodromal symptoms are not peculiar to 



LEPROSY 437 



leprosy. It may need to be differentiated from syphilis, lupusj erythema 

multiforme, tinea versicolor, leueoderma and morphcea. 

Syphilitic macules are smaller, less colored, less permanent than those of 
leprosy, and do not seek the face. The tubercles of syphilis which may be 
closely simulated by lepra lesions are smaller, of a deeper red color, more 
grouped, ulcerate more readily and are more indiscriminate in their location, 
while leprosy has a predilection for the face, ears, hands and anna. \ 
often when syphilis exists a history or other evidences of the disease may be 
found. The two diseases may sometimes coexist. 

Lupus nodules are softer than those of leprosy, smaller and more circum- 
scribed, grouped in patches in which scar tissue is often found, and do not 
produce the extensive thickening of the brows and ears frequently resulting 
from the latter. Lupus erythematosus lacks the anaesthesia and other neu- 
rotic symptoms of macular leprosy, and is much less apt to show multiple 
lesions. 

Erythema multiforme and the erythematous spots of early leprosy may be 
very like in appearance. The sites of predilection are different, the spots are 
larger in leprosy, tend to become nodular and are slower in their involution 
in comparison with the sub-acute coiirse, and progressive gradations in color 
of multiforme erythema. 

Tinea versicolor and the pigmented spots of anaesthetic leprosy may be 
easily differentiated by the fine scaliness of the surface of the patches in the 
former, a discovery of its characteristic fungus and an absence of sensory 
changes. 

Leueoderma and the achromic spots of leprosy possess little in common 
except loss of color. The former are more irregular in outline, whiter and 
more sharply defined by a pigmented border, but the patches are otherwise 
normal in texture and sensibility. In leprosy there is not only loss of pig- 
ment, but the skin is atrophic, depressed and more or less anaesthetic. 
Morphea can always be distinguished from the atrophic patches of leprosy 
by its hard, lardaceous waxy-white surface and its violaceous border. 

Finally in doubtful cases a microscopic examination of the fluid obtained 
from a leprous tubercle will reveal the characteristic leprous bacillus, while 
in anaesthetic leprosy the loss of sensation is always diagnostic. 

Prognosis. — Rarely is leprosy cured. There may be long periods of 
arrest in its progress, but sooner or later the advance is renewed and goes 
on finally to a fatal issue. Exceptionally the disease subsides spontaneously 
or from treatment and does not return. Cases of recovery have been noted 
where the patients ultimately died from some other cause. Removal to a 
temperate climate early in the course of the disease favorably affects the 
prognosis. 

Treatment. — Efforts to prevent the spread of leprosy have been directed 
chiefly to measures for segregation. The isolation of lepers afflicted with 
open (ulcerating) lesions is undoubtedly demanded for the protection of a 
community in which they happen to be dwelling, because discharges from 



438 LEPROSY 

such sores are loaded with bacilli, but there is no just ground for depriving 
persons afflicted with the non-ulcerative or macular form of the disease of 
their liberty, because it cannot be proved that they are contagious or danger- 
ous to the public health. As a matter of precaution, the latter case might be 
listed and occasionally examined for any development which would menace 
the safety of others. Systematic segregation and improved ways of living have 
greatly diminished the prevalence of leprosy in Norway, where there are now 
only about five hundred cases, of whom one-half live comparatively unre- 
stricted outside of hospitals. The bacillus leprae probably does not live out- 
side the human body, and hence, under conditions which exist in the eastern 
part of this country, the disease is more likely to die out than to spread if 
the very few ulcerative cases are properly cared for in private or public "insti- 
tutions. In the latter cases all discharges from the skin or mucous passages 
should be sterilized or burned up to prevent all possible infection. 

There are no specifics for the cure of leprosy. Methods of treatment which 
have been announced as beneficial by some have been later pronounced ineffec- 
tual by others, so that to-day there is no practical unanimity regarding treat- 
ment, especially by internal medication. All observers agree as to the good 
effects following from improved ways of physiological living. Change to a 
temperate climate, plenty of sunlight, outdoor exercise, a plain and nourishing 
mixed diet, suitable clothing, systematic bathing and inunctions of the skin 
with oil all help to build up a resistance to the disease. Leprosy seeks the 
exposed surfaces of the body, and cold or chill is believed to be an exciting 
cause of its activity. The avoidance therefore of unnecessary exposure and the 
exercise of care in wearing sufficient clothing for protection may be important 
items in the management of a case. 

Locally, inunctions of oil may be employed in all cases, as it is always 
grateful to the skin of the leper, owing to the tendency to dryness. Chaul- 
moogra oil is most highly recommended for local use in the proportion of 
one to fifteen of sweet oil. It has been given internally at the same time in 
three to eighty drop doses in emulsion or capsules three times a day ; it is verv 
irritating to the stomach and cannot often be given in large doses, which are 
said to be most effective. 

Gurjin oil has been employed with reported good effects; internally in 
doses of one or two drachms with an equal part of lime water, and locally 
diluted with three parts sweet oil or in emulsion with the same quantity of lime 
water. Oil of anacardium occid. and oil of hydnocarptis ineb. have been recom- 
mended. The latter is said to have the most rapid effect, given in ten to thirty 
drops mornings in hot milk, and applied locally twice a day. The diet at the 
same time is chiefly limited to eggs, milk, butter, mutton, fowls, vegetables and 
fruit. Alcoholic drinks, tea, coffee, beef, pork and fish are not allowed. 

Impey states he has seen very little effect from the use of several of these 
oils, and others are inclined to believe that the use of the simple linseed or 
olive oils is nearly as beneficial, the main effect arising from the frictions 
rather than from the peculiar nature of the oil. 







Fig. 119— LEPROSY 



MACULAR AX.ESTHETIC VARIETY 



Patient is a well-developed boy of fourteen, born in this country, but who pre- 
vious to a few months ago lived in South America for several years. Disease began 
about two years ago in the form of sensitive reddish macules on the back of the right 
thigh above the knee. These faded in color at times, but gradually enlarged, coal- 
esced with other spots which appeared below the knee, and after months united in 
a yellowish-red area shown in Fig. 120. During the first year similar lesions developed 
on the left breast, later on the left side of back just below the loin and pursued the 
same course. All the affected areas are completely anaesthetic to pain except at the 
darker moderately elevated and advancing borders, which are perceptibly hyper- 
aesthetic. Temperature sensation is diminished except over the middle patch on 
the breast, where it seems to be abolished. The color varies from a yellowish-red to 
a brownish hue, except at the margins, where the process is active, it is more dis- 
tinctly red. On the leg the surface is nearly smooth, almost shiny in spots, as though 
atrophy was beginning, while on the breast desquamation is most apparent. Cured 
with hydrocotyle, sixth decimal. 







Fig. 120.— LEPROSY 
Same case as depicted in Fig. 119. 



LEPROSY 189 

Many local reducing, stimulating or antiparasitic agents have been tried 
on leprous lesions, but without any certain effect. Unna recommends an 
ointment containing five per cent, each of chrysarobin and khthyol and two per 
cent, of salicylic acid. He uses resorcin in place of chrysarobin for women 
and children. When the lesions break down and ulcers form, the indica- 
tions for local treatment are the same as for any contagious sore, cleansing 
and dressing with antiparasitic and deodorizing applications when possible. 
Salicylate of soda ointment is chiefly employed in Norway, and Impey men- 
tions iodoform ointment as the most beneficial application and of its odor 
being actually appreciated by leper patients. Oakum or other absorbing 
material can be placed over discharging lesions. 

Surgical measures are sometimes indicated. Nerve stretching has proved 
beneficial in anaesthetic leprosy for the neuralgic pains along the trunks of a 
nerve, and in healing perforating ulcers of a part supplied by a nerve. Masses 
of tubercles may be sometimes excised, necrosed bones removed and ulcerating 
surfaces curetted with benefit to the patient. Surgical wounds heal rapidly, 
owing to an excess of fibrin in the leper's tissues. Tracheotomy or intu- 
bation may be required for stenosis of the larynx due to leprous growths 
in the pharynx or larynx. In rare cases tubes have been worn for several 
years and finally discarded with a relief of the obstruction. Galvanism has 
proved useful in helping to restore the function of the sensory nerves in 
anaesthetic patches. 

The internal administration of oil has been mentioned. Besides these, 
such drugs as carbolic acid, sulpho-ichthyolate of sodium, salicylic acid and 
salicylate of sodium, salol, creosote, arsenic, iodide of potassium, nux vomica, 
strychnia, and hoang nan, have been given in full doses with reported favorable 
effect in the hands of some and without benefit in the observation of more. 
Chaulmoogra oil in tubercular and mixed cases, and strychnia in the tropho- 
neurotic form, according to Morrow, give the best results. 

It is not improbable that cases of leprosy amenable to treatment might 
respond to drugs selected after a careful individualization of each one. My 
own limited observation supports this view. One of my cases of macular 
anaesthetic leprosy, which had been steadily advancing, was apparently arrested 
and later cured on Hydrocotyle 3x, without local treatment. A case of mixed 
leprosy seen once was later reported to have improved on Sepia and the local 
application of a five per cent, salicylic acid collodion to the few lesions on the 
face, one of which had begun to ulcerate. A number of other drugs show 
conditions or symptoms in their pathogenesis resembling those of leprosy. 
See indications for Arsen., Aurum mur., Cal. phos., Kali brom., Lach., Merc, 
Nit. acid, Pet., Phos., Rhus tox., Secale and SUicea. 



440 YAWS 



YAWS 

(Frambcesia; Polypapilloma tropicum, etc.) 

Definition. — An infectious and contagious disease of the tropics, char- 
acterized by the evolution of an eruption in stages up to a fungoid tumor, 
which may remain stationary for a time and then gradually disappear 
without leaving any ultimate trace, or, less often, break down and form 
ulcers. 

Symptoms. — The stage of incubation lasts from one to two weeks, during 
which there may be loss of appetite, feverishness, perspiration, pains in the 
extremities and languor, but no symptom special to the disease. These pro- 
dromata are often absent in adults. 

The stage of eruption is sometimes preceded by a dry, scaly condition of 
the surface, before the characteristic papular lesions gradually appear in vari- 
ous parts of the body, attended with swelling and tenderness of the lymphatic 
glands. The primary eruption is completed in about two weeks, and consists 
of pin-head sized papules with yellowish points, bordered by a red or darker 
areola. In the next stage the papules begin to enlarge, especially in breadth, 
and become covered over with yellow crusts. As one of these lesions reaches 
the size of a tubercle the crust falls away, leaving exposed to view a fungus- 
like surface from which exudes a yellowish, offensive and adhesive fluid. 
These growths may reach a quarter of an inch in diameter at the top, smaller 
at the base, and sometimes become confluent in a large patch; they are hard, 
freely movable with the skin and reach their acme of development in one to 
two months. The appearance of these growths in the skin has been compared 
to a raspberry, strawberry or mulberry. 

After a variable time the stage of retrogression begins. The tubercles 
shrink in size, crusts fall off and are replaced by small adherent scales covering 
a dry surface; the color of the lesions grows darker and the border lighter 
as involution goes gradually on, until finally, in eight weeks to as many months 
after the beginning of the disease, only a dark spot remains to mark the site 
for a time, to in turn disappear. Occasionally the growths may ulcerate and 
the destructive process extend into the surrounding tissues, resulting in scars ; 
rarely, too, the bones of the hands or feet may be involved and deformity result. 

Sometimes variations in the manifestations of the lesions are seen. 
Crocker has given the name " ringworm yaws " to ring-like patches formed by 
a coalescence of lesions around the mucous outlets. Among the native laboring 
class ulcers may form on the hands and feet. These may spread irregularly 
and protrude somewhat like the shape of a crab and so have been called 
" crab yaws." 

The sites of predilection for yaws are given as at or about the outlets of 
the body and other parts exposed to injury. 

Etiology and Pathology. — A tropical climate is apparently an essential 



YAWS 1 1 1 

condition for the development of this disease. The colored race are most 
subject to it, and while it may occur at any age, children are more commonly 
attacked. It is probably always due to inoculation in some abrasion of the 
skin, and one attack is usually protective against further inoculation. The 
specific virus or microbe which is believed to cause this disease is described by 
Pierez as a rod-shaped bacillus, occurring singly, in couplets or triplets. It 
may be cultivated in nutrient jelly, and has produced by transference the dis- 
ease not only on the skin of man but also upon that of the lower animals, 
especially the cat. 

The pathological changes induced by the presence of the poison in the skin 
are somewhat like those of syphilis, but according to Unna more simple in 
construction. In brief, the changes consist of a cellular infiltration in the 
cutis, hypertrophic elongation of the papillae to ten or twenty times their 
normal length, overgrowth and hyperkeratosis of the epidermic cells. The 
latter produces the hardness and dryness of the surface of the lesion. When 
the crust is removed the prominent papillae covered only with a thin layer of 
prickle cells gives the raspberry-like appearance to the tumor. 

Diagnosis. — The limitation of this affection to tropical regions, the 
peculiar evolution of its lesions, duration, etc., clearly distinguish it from 
other cutaneous diseases. The supposition that it closely resembles syphilis 
in nature or lesions is denied by those who have had opportunity to observe 
both diseases in detail. Daniels, from observation of the disease in Fiji, says: 
"The eruption has no resemblance to primary or secondary syphilis, and shows 
none of the associated lesions, and if considered as a tertiary manifestation 
there are neither primary nor secondary stages, for throughout it shows 
lesions of exactly the same character." The early lesion of yaws is not indu- 
rated like a chancre, does not tend to become phagedenic and is rarely genital. 
In the next stage it is not symmetrical or polymorphous like secondary syphilis, 
and the mucous membranes are never affected until later, sometimes years 
after. It is said, however, that syphilis and yaws often coexist in the same 
persons in countries where the latter is endemic. 

Verruga, an epidemic disease occurring in the valleys of the Peruvian 
Andes, would scarcely be confounded with yaws. The former is characterized 
by a polymorphous eruption, pronounced anaemia, stiffening of the joints, 
muscular pains and spasms, and is often fatal. Psoriasis and eczema might 
be mistaken for yaws or vice versa, but the peculiarities of each are distinctive. 

Prognosis is favorable except in infants and debilitated subjects. 

Treatment. — This should be based upon the indications as they arise. 
The hygienic and sanitary conditions of and around the patient should be made 
as perfect as possible, by attention to diet, ventilation, bathing, etc. 

Locally, owing to the inoculability of the disease, cleanliness is important 
and antiseptic protective dressings are indicated when the lesions are few or 
grouped together. Corrosive sublimate soap ought to be well adapted for sys- 
tematic bathing, and it is quite possible that painting the smaller lesions with 
salicylic acid or iodized collodion might arrest their development as well as 



442 EQUINIA 

afford a protective covering. If ulcers form they should be treated like other 
contagious sores, dusted over with antiseptic powders, like boric acid, iodo- 
form, aristol, etc., or ointments of the same, and' covered with absorbent cot- 
ton or gauze. 

There is very little data from which to estimate the value of internal treat- 
ment, but the pathogenesis of the disease is not without indications for such 
drugs as Merc, biniod. and Nit. acid. 



EQUINIA 

(Glanders; Farcy; Matteus.) 

Definition. — A rare, acute or chrtfnic contagious disease attended with, 
constitutional disturbances and lesions of the skin and mucous membranes, 
due to inoculation with a specific virus derived from a horse or other equine 
animal affected with glanders or farcy. 

Symptoms. — Following accidental infection, through some abrasion of the 
skin or through the sound mucous membrane, there is a variable period of in- 
cubation of from three days to as many weeks. At the end of this period vague 
general symptoms of a rheumatoid character appear, such as mild fever, pros- 
tration, pains in the extremities, constipation, etc. After a time chills or 
rigors may make an increase of febrile disturbance, with profuse perspirations 
and diarrhoea; when the attack is severe a typhoid or pyaemic condition may 
develop and terminate in death in a few days. 

Meanwhile at the point of inoculation the skin becomes painful, red and 
tense, and a chancroidal-like ulcer forms with or without the previous appear- 
ance of a papule or pustule. The ulcer spreads by an undermining process 
at its edge, looks foul, often gives rise to an offensive discharge and is soon at- 
tended with swelling of the neighboring lymphatic glands and often with 
lymphangitis. Sometimes more or less extensive phlegmonous inflammation 
may characterize the primary process, with the later appearance of pustules 
and ulcers at various points on the surface. If the entrance of the poison 
occurs through a mucous membrane catarrhal symptoms appear, followed by 
those of ulceration, with a purulent, sanious and offensive discharge. The 
nasal mucous membrane is commonly the part attacked, and the soft parts may 
be destroyed and the bones perforated. The disease may begin on other mucous 
surfaces or may extend to them from the nose with corresponding symptoms. 
Even when the inoculation takes place through the skin the mucous mem- 
branes become affected later in most acute or sub-acute cases. 

The more characteristic skin eruptions of equinia arise irrespective of the 
point of inoculation, and may appear at any time from two days to a month 
after the development of the early symptoms. They begin under the epidermis 
in groups of red spots, which soon become shot-like papules, and as they change 
to yellow look like the lesions of smallpox, but are not umbilicated. These 



EQUINIA 

may merge together, break down and form superficial, ragged, dirty ulcers, or 
sometimes dry, gangrenous patches. Deeper and larger nodules may appear 
at points distant from the primary infection and are sometimes connected by 
swollen lymphatics. These glandular enlargements may reach the size of a 
walnut ; in the horse they constitute the " farcy buds," which may be numerous, 
and if they do not resolve, break down into deep and foul ulcers. In some acute 
cases these eruptions do not develop owing to the rapidly fatal course of the 
disease; in chronic cases they are not numerous or of rapid development, cor- 
responding with the more moderate constitutional symptoms. The average 
duration of chronic cases is five or six months, but it may be much longer in 
exceptional instances, and rarely the acute form may supplant the chronic at 
any time in its course. 

Etiology and Pathology. — Glanders in man is limited almost exclu- 
sively to those male adults who have to do with horses, very few cases having 
been known to occur by transmission from man to man, woman or child. The 
mode of contagion is probably nearly always direct, from the contaminated 
secretions of the animal coming in contact with an abrasion of the skin or the 
unguarded mucous membrane. 

The pathological cause is known to be the glanders-bacillus (bacillus-mal- 
lei), which has produced the disease from culture inoculations. This microbe 
is about the size of the tubercle bacillus, broader, but somewhat shorter, and is 
easily stained with methylene blue. It is found in the discharges from the 
lesions of glanders and may retain its vitality for some time in a dry state, but 
is destroyed at a temperature of 135° F., and by ordinary antiparasitics. The 
presence of the bacilli or their products in the human tissues causes a dense in- 
filtration of embryonic cells in the corium, very like the process in tuberculosis. 
Infection spreads along the lymph-vessels, and bacilli may enter the blood- 
vessels and be carried to other near or distant parts of the body. Extensive or 
numerous foci may finally induce a condition akin to pyaemia. The bacilli 
are abundant in all the skin lesions, blood and brain tissue. 

Diagnosis. — When equinia is suspected from the history of a case an in- 
quiry should always be made regarding the occupation of the patient, and. it' 
this clue of its origin is lacking, a microscopic examination of the discharges 
should be made for the specific bacillus. When the general, cutaneous, lymph- 
atic and mucous membrane symptoms have appeared little difficulty will be 
found in making a diagnosis. 

The prognosis is grave in proportion to the acuteness of the attack. Most 
acute cases are fatal, and about one-half of the chronic ones finally die from 
the disease. 

Treatment. — Preventive treatment consists in the immediate killing, dis- 
infection and burial of animals affected with glanders; thorough sterilization 
and protection of abrasions or wounds happening to those caring for suspected 
animals, and the early excision and antisepsis of the skin at any point where 
inoculation is suspected to have taken place. After the development of the 
disease the patient should receive physiological treatment to put him in the 



444 ERYSIPELAS 

best condition to resist the disease; strict local antiseptic dressing of open 
lesions, .and the indicated remedy. One case of the editor's involving both 
hands and arms with extensive lymphangitis improved markedly while treated 
locally with constant applications of a ten per cent, solution of creolin in 
glycerine. It has been reported that a toxin (mallein) of the bacillus, injected 
subcutaneously, gave favorable results. 



ERYSIPELAS 

(St. Anthony's fire; Ignis sacer; Rose; Wildfire.) 

Definition. — An infectious inflammation of the skin and contiguous 
mucous membranes, attended with febrile and other systemic disturb- 
ances, characterized always by redness which tends to spread, frequently 
by the development of vesicles, blebs and pustules, less often by diffuse 
suppuration and gangrene. 

Symptoms. — The special features of surgical erysipelas need not be taken 
up here. It being generally admitted that the efficient cause of erysipelas is 
always the same, the former division into idiopathic and traumatic is no longer 
important or necessary. 

The general symptoms often begin with a sense of malaise and prostration, 
and are followed in a day or so by chills, vomiting, etc. Sometimes these are 
mild or wanting and fever marks the onset as well as the course of the disease. 
The temperature varies from 101-106 and is persistent, with an evening rise 
and morning remission except in the mildest cases when it may nearly subside 
after a few hours or days. A rise of fever usually indicates an extension of the 
disease, and a fall an arrest or subsidence of the inflammation. The pulse is 
quickened usually in proportion to the degree of fever, and its other qualities 
vary not alone from the intensity and extent of the disease, but also from the 
previous condition of the patient due to habits or disease. Headache is often 
a prominent symptom, and drowsiness and delirium are not uncommon, espe- 
cially when the attack is located on the head. 

"Within a few hours to a day after the general symptoms begin local signs of 
erysipelas appear at the point of infection. This is at first a small distinctly 
red, shiny, swollen, irregular and sharply defined spot. The color disappears 
on pressure except a yellowish tinge, but the redness returns quickly on removal 
of the finger ; sometimes the color is violaceous or livid. The part is painful on 
pressure, hot and tense to touch, but the amount of swelling varies widely with 
the region affected, being greatest where the areolar tissue is abundant and 
loose, and least where it is moderate and firm. On the face erysipelas often 
completely closes the eyes from swelling of the tissues about them, while on 
the scalp it may cause only slight elevation. As a patch of erysipelas enlarges 
more or less rapidly it preserves its sharply defined border against the sound 
skin. It may spread at all or several points or chiefly in one direction; some- 



ERYSIPELAS * »•"• 

limes it is very erratic in its march, advancing first at one part of the periphery . 
and again at another, or again by apparent metastasis to another region. The 
extent of surface finally involved may be comparatively small or large ; involu- 
tion often goes on in the older portions as new areas are invaded. Barely the 
entire body may be progressively visited in this way (erysipelas ambulans), 
and even a second time in the same manner. 

Erysipelas may run its course without developing other lesions, but when 
the process is intense enough the pressure of exudation in the epidermis may 
rise to the surface in vesicles or bullae. The contents of these may become 
purulent and then dry into crusts. Prolonged and intense compression of the 
capillaries of the skin may induce gangrene, especially of dependent parts. 
Eed streaks along the skin show the involvement of the lymphatics, and the 
enlarged glands may suppurate, or furunculous-like abscesses may form in 
severe cases. 

The most common location of erysipelas is on the head or face, but no 
portion of the skin is immune to the disease. When the scalp is involved 
symptomatic alopecia follows during convalescence, later the growth of hair 
is generally renewed again. Eepeated attacks of erysipelas in the same place 
may lead to permanent changes in the skin, such as elephantiasic conditions 
of the legs and thickening of the skin of the face, ears, lips, etc. 

The point of origin of the disease appears to be often about the nose, prob- 
ably because the skin and mucous membrane are frequently slightly abraded 
by the nails, and the fingers so commonly touch these parts, but in the majority 
of cases no injury of the surface is discoverable. The inflammation is liable 
to spread from the nose into the mouth and throat, or beginning at some point 
in the mucous structures it may extend on to the skin. The affected mucous 
membrane is swollen, dry, glazed, and over the tongue may be fissured ; exces- 
sive secretion of saliva is sometimes noted. When the pharynx is invaded 
deglutition is painful, and oedema of the glottis may arise as a dangerous 
complication. 

The duration of erysipelas varies from one to three weeks and exhibits 
all grades of severity. Sometimes it runs a very mild course, with slight fever 
and little general disturbance of the system ; at the other extreme, particularly 
in old people, alcoholics, and in persons suffering from nephritis and diabetes, 
prostration is often an early feature, and delirium, drowsiness or coma may 
soon mark the gravity of the attack. Serous effusions into the lungs or brain 
may hasten the closing scene in fatal cases. Milder attacks may be prolonged 
by recurrences in the same or other portions of the surface. 

Local recovery is indicated by a subsidence of the heat, swelling and redness, 
but involution is generally slow and may be interrupted by a renewal of the 
disease in some degree or by complicating boils or abscesses. 

Etiology and Pathology. — It is generally believed that the disease arises 
from local infection through some break in the continuity of the skin or 
mucous membrane, however minute. Hence, any lesion of the surface may 
afford a starting point for erysipelas. Larger wounds from traumatisms 



446 ERYSIPELAS 

and surgical operations are most readily infected and favor the assumption 
that no special condition of the tissues other than exposure is necessary to 
permit infection with the poisonous element of the disease. Lowered or 
perverted nutrition from intemperance and other hahits or from disease, 
exposure to cold and chronic cutaneous disease may be said to be predispos- 
ing causes. One attack apparently predisposes to another, either from latent 
foci or from greatly diminished resistance of the tissues. 

The efficient or pathological cause of erysipelas is conceded by most au- 
thorities to be a specific streptoccocus described by Fehleisen in 1882. This 
organism gains an entrance into the tissues directly or indirectly, there 
multiplies and produces products which give rise to the characteristic in- 
flammation, systemic fever, etc. The streptococci have been found in the 
lymph vessels of the skin down into the subcutaneous layer, and both the 
venous capillaries and lymphatic vessels and lymph-spaces are enormously 
dilatedT" They are brought into view by staining a section of tissue with 
methyl-violet, and then may be seen under the microscope in chains of two 
or more and bunched together. Staphylococci are also claimed as a cause. 

The type of inflammation excited by these micro-organisms is sero-fibrin- 
ous, implicating chiefly the deeper portion of the corium and extending into 
the subcutaneous tissue. The exudation into the latter structure accounts 
largely for the induration always felt and its' slow absorption during involu- 
tion, while the more permanent thickening of the skin which sometimes 
follows recurrent attacks is explained by the progressive conversion of wander- 
ing cells (by fibrillary union) into connective tissue, finally reaching ele- 
phantiasic enlargement. The epidermis is penetrated and sometimes lifted 
up by the exudation; vesicles or bulla? form deeply at or below the base of 
the granular layer; and the hair follicles may be penetrated and the sheaths 
dissected from the roots, resulting in loss of the hair. 

Diagnosis. — Due attention to the history of an attack will seldom fail 
to show the diagnostic symptoms of erysipelas. The early chills and con- 
secutive fever which usually continues, the red, swollen and abruptly defined 
patch spreading more or less steadily in a regular or irregular manner are 
sufficiently characteristic. It is possible, however, to confuse the disease 
with acute eczema, erj^hema and giant urticaria. 

Eczema is not attended with systemic fever except in young children, 
who are not likely to be attacked with erysipelas; the eczematous patch is 
not as swollen, bright red or sharply defined as in erysipelas; vesicles which 
form on the surface are minute, thickly set and perhaps more perceptible 
to touch than to sight; often the surface is dry and scaly, and the whole 
process is attended, as a rule, with marked sensations of itching. 

Erythema is of short duration; unattended with fever, or any tendency 
to creep out over the surface; the redness disappears wholly on pressure 
without leaving a yellowish stain, but quickly returns when pressure is re- 
moved. Urticaria is ephemeral in character; not attended with marked sys- 
temic disturbance; nearly always shows the characteristic wheals or a history 



ERYSIPELOID 447 

of their occurrence, without tenderness, but with pronounced sensations of 
itching or stinging; and very often signs of digestive or other internal dis- 
turbances of function. 

■ Prognosis. — Uncomplicated cases of erysipelas commonly recover. Fol- 
lowing obvious traumatisms from accidents, surgical operations, labor, etc., 
the probabilities are less favorable. When the disease attacks the umbilicus 
of the new-born it is said to be commonly fatal. Old age and a long duration 
of the attack are looked upon as obstacles to recovery. Existing disease and 
complicating conditions arising in the course of erysipelas may materially 
diminish the prospects of cure and prolong its duration. 

Treatment. — Inasmuch as the microbe of erysipelas carries on its work 
deep in the tissues of the skin, no local measures of treatment are demanded 
other than absolute cleanliness and taose which afford protection to the 
skin and comfort to the patient. The parts may be washed with a 1 to 
3,000 bichloride solution, and cloths, made to fit over the region affected, 
may be wet with this or with a dilution of the same drug which is adminis- 
tered internally, or with dilute calendula, hamamelis, or alcohol. These 
give local comfort, but probably do not shorten the course of the disease to 
an appreciable extent. For cure we must rely on sustaining physiological 
treatment and the indicated drug. The diet should be nourishing in pro- 
portion to the prostration or danger therefrom in each patient; and alcoholic 
stimulants may be needed for a time in grave cases. Quiet and isolation 
are essential provisions for the patient's welfare; rules of cleanliness should 
be enforced to prevent possible auto-infection and the transmission of the 
disease to others. In this connection the liability of nurses and physicians 
conveying the poison to other patients, especially surgical and puerperal 
cases, should never be forgotten. 

The treatment of erysipelas with drugs administered internally may be 
viewed with considerable confidence. Observation of a large number of cases 
in hospital and private practice leads the author to believe their value is 
underestimated, and that the disease is not only modified in intensity and 
course, but the rate of mortality minimized by their judicious employment. 
The number of drugs likely to be indicated is not large and their sphere of 
action comparatively well known. Look particularly at the indications for 
Apis, Am., Arsen., Bell., Canth., Crotal., Euphor., Lach., Rhus tox., and 
Vipera. 



ERYSIPELOID 

An efflorescence on the skin resembling erysipelas somewhat, but probably 
most often looked upon as an erythema, was first named erysipeloid by Rosen- 
bach. It is believed to be due to the inoculation of some slight wound with 
decaying animal matter, and occurs chiefly on the fingers of cooks, fish 
dealers, butchers, or those habitually handling the flesh of animals. It 



448 ERYSIPELOID 

begins at the point of poisoning as a dark red or livid papule, and then 
spreads therefrom as a sharply defined erj'thema, which, as it clears in the 
central portion, may assume circular or festooned patches. It may creep over 
the surface in one or more directions, is attended throughout its whole course 
with pronounced burning or itching sensations, and ceases spontaneously in 
one to five weeks. 

Pathology. — Eosenbach holds that the efficient cause is a micro-organ- 
ism of the order cladothrix, existing in putrid flesh or cheese. He claims to 
have induced the disease from pure cultures of the organism. However, 
other observers do not verify this statement. 

Diagnosis. — The absence of constitutional symptoms may differentiate 
erysipeloid from erysipelas. Dermatitis repens, erythema multiforme and 
ringworm may need to be considered. 

Treatment. — The local application of a weak solution of formalin or 
permanganate of potassium or a weak ointment of resorcin, ichthyol or am- 
moniated mercury, will hasten resolution. Arnica might be indicated in- 
ternally. 




Fig. 121.— FIBROMA MOLLUSCUM 

Subject is a deformed man of about fifty who has never been very strong, 
mentally or physically. The growths began in childhood and have gradually multi- 
plied. The lesions consist of hard and soft sessile and pedunculated tumors, varying 
in size from a pin-head to an orange, and most numerous on the trunk, though no 
region is entirely exempt other than the palms and soles. The largest growth is 
attached to the skin above and hangs over the crest of the left hip, and on which the 
left elbow is shown as resting. 







Fig. 122.— FIBROMA PENDULUM 

Subject is a woman of seventy years. Tumor has slowly 
grown for years, is freely movable, painless and hard. (Cour- 
tesy of Dr. W. H. Bishop.) 



FIBROMA AND NEUROFIBROMA H!) 



CLASS VI.-NEW GROWTHS-NEOPLASMATA 

This group comprises a list of diseases characterized by a more or less 
pronounced infiltration or growth of new elements in the skin and some whose 
etiology is not clear enough to justify a place among any of the preceding 
classes. For instance, more complete knowledge of the etiology and pathology 
of Acromegaly, Colloid Degeneration of the Skin, Lupus Erythematosus, Ver- 
ruga and Myxcedema will probably place them more appropriately in other 
groups. 

New growths may be naturally divided: (1) According to their structure 
into connective tissue tumors and epithelial tumors; (2) according to their 
nature into benign and malignant. Combining these distinctions four groups 
may be found as follows: (A) Benign Connective Tissue Growths. (B) 
Benign Epithelial Growths. (C) Malignant Epithelial Growths. (D) Malig- 
nant Connective Tissue Growths. 



A. BENIGN CONNECTIVE TISSUE GROWTHS 

FIBROMA AND NEUROFIBROMA 

(Fibroma molluscum; Molluscum simplex; Molluscum pendulum.) 

Fibroma is a new growth, consisting of fibrous connective tissue. 

True fibroma of the skin (fibroma durum, desmoid hard fibroma) is not a 
common tumor. It is usually single and appears as a firm, slowly growing 
nodule, of small size and movable with the skin. . The tumor is usually pain- 
less and does not recur after removal. In its histological structure, the true 
fibroma resembles the dense fibrous tissue of the cutis vera, with broad bands 
of fibres and few corpuscles of any kind. No elastic fibres have been demon- 
strated in the new tissue. 

The multiple tumors that are usually called fibroma molluscum or soft 
fibromata have been shown by Von Kecklinghausen to be, in reality, neurofi- 
bromata; that is, fibrous tissue tumors that grow from the connective tissue 
sheaths of the cutaneous nerves, usually at the peripheral end of the nerve. 
The minute structure of these neurofibromata differs from that of true fibroma 
in being composed of loosely woven fibres entangling multitudes of round and 
spindle cells. The abundance of cells may give the tumor a close resemblance 
to sarcoma. 

Clinically, the -fibroma molluscum or neurofibroma appears in the form 
of one or more nodules intermediate in consistence between the flabby soft- 



450 FIBROMA AND NEUROFIBROMA 

ness of a lipoma and the firmness of a true fibroma or a myoma. The tumors 
vary in size from a hempseed to a cherry, may enlarge slowly or rapidly, and 
sometimes reach an enormous size ; they may remain stationary after attaining 
a certain variable size, either sessile or become, pedunculated. On careful 
palpation, there are often found, at the base of the tumor, several hard cords 
or roots; these represent the thickened nerve trunks from the branches of 
which the tumor has grown. Neurofibromata are nearly always multiple; 
there may be hundreds of sessile and polypoid growths covering almost the 
whole surface of the body. Neurofibromata are usually painless; exception- 
ally, pain will be acute from pressure on some nerve. The tumors are benign, 
persist throughout life and they are apt to recur after excision. They do not 
appear to affect the general health, except through mental annoyance at their 
presence, or from mechanical discomfort when large. 

Dermatolysis (fibroma pendulum; lax or relaxed skin) is a condition which 
is usually congenital or secondary to fibroma. The skin in such cases may 
be gathered up in flaps between the fingers and is thickened, of a natural 
hue or pigmented in color, and usually possesses the normal functions of skin. 
It is always limited in extent and favors the face, neck, chest, abdomen or 
genital region. This condition of relaxed skin should be differentiated from 
those forms due to senility, or to distension after the presence of tumors or 
pregnancy. 

The etiology of these growths is not known. They have been attributed 
to hereditary influence from their occasional appearance in several members 
of the same family or in successive generations. Some degree of mental or 
physical weakness has often been noticed in these patients. The tumors may 
develop at any age and are sometimes present at birth. In this country, the 
negroes furnish the largest number of cases. 

Diagnosis. — The slow growth, number, isolation, unchanged color and 
consistency of fibromata, and the absence of constitutional symptoms make 
their recognition easy. 

From molluscum contagiosum they may be distinguished by being of the 
same color as the skin, by the absence of umbilication, deeper attachment in 
the skin, and usually greater number. From lipomata by their non-lobulated 
character, by being pedunculated and less flat. From neuromata by the 
absence of pain ; from papillomata by their smooth surface ; and from multiple 
sarcomata by their slow growth, absence of redness and any tendency to break 
down. Sebaceous tumors (wen) are rarely numerous, not pedunculated and 
their contents can often be expressed by first dilating the mouth of the follicle, 
unlike the solid fibromata. 

Peognosis and Teeatment. — There is probably no cure known for well 
developed fibroma molluscum. That cure is possible is perhaps indicated by 
rare instances of spontaneous involution. In the incipient or early stage 
remedies known to act on connective tissue or indicated by existing constitu- 
tional conditions may be given. Hard fibromata may be excised and are not 
likely to return. Neurofibromata may also be excised when so situated or large 



KELOID 451 



enough to give annoyance; or electrolysis may be employed to destroy them 
when not too large. But, however removed, they are likely to return. Among 
possible remedies see Gale, fluor.. Graph., I/ycopodium. 



KELOID 

(C keloid; Kelis.) 

Keloid is a new growth of the skin composed of dense fibrous tissue 
which has its seat in the corium. It differs from fibroma in its peculiar 
appearance and its persistency. The peculiar appearance of keloid is the prin- 
cipal diagnostic feature. It consists of an elevated variously shaped patch or 
ridge of skin, the surface of which is tense, smooth and shining and of a 
pearly or rosy tint. At one or both ends of the ridge there may be several 
fleshy prongs that blend gradually with the surrounding skin. The growth 
is found most often over the sternum, chest and neck, but may appear on 
any part of the surface. As a rule, keloid occurs only after some injury to 
the skin. Some dermatologists distinguish between "spontaneous keloid" 
and "keloid following injury," but it is probable that all keloids develop after 
some injury, however slight, as simple scratching of the skin. It is usually 
a single growth, but may be multiple, and also vary greatly in size and shape. 
When excised keloid nearly always recurs. It is a benign tumor and never 
threatens life, though it may be the seat of considerable pain. 

Around a healing or healed wound there sometimes develops a mass of 
fibrous tissue that is called "false keloid" or "hypertrophic scar." It differs 
from true keloid in the fact that it often disappears spontaneously and never 
recurs after removal. 

Etiology. — The cause of keloid is not known. It is seen in both sexes 
and most often in the middle period of life ; cases, however, have been observed 
at nearly all times of life. The dark skinned races are more subject to the 
disease, and many cases have been traced to slight injuries. It is probable 
that some cases may in the future be considered as examples of cutaneous 
paratuberculosis, since the disease is more common in a race prone to general 
tuberculosis and since the lesions often recur after excision and may present 
a marked lupoid character. 

Diagnosis. — The ridge-like shape, smooth surface, pinkish color and his- 
tory of occurrence will nearly always serve to distinguish keloid from all other 
growths. A hypertrophic scar might approach it in appearance, but a history 
of a wound at the exact site of the lesion, lighter color, less elevation and 
absence of pain common to cicatrices will readily differentiate the latter from 
the former. 

Prognosis. — A keloid may disappear spontaneously, but usually persists 
indefinitely though the patient's general health is not affected. 



452 CICATRIX 

Treatment. — While radiotherapy has given satisfactory results in a few 
keloids only, it has been distinctly successful in the treatment of hypertrophic 
scars. High frequency currents (Oudin resonator) have been of benefit in a 
larger proportion of cases of keloid than the Kontgen-rays. 

Excision and cauterization are of no avail because the growths return. 
Vidal has employed multiple linear scarifications with success. The tumors 
may be destroyed by electrolysis, but this and other operative measures are 
only justified when the growths are conspicuous in location, very painful or 
interfere with some function. Among drugs see Gal. fluor., Fluor, acid, 
Graph, and Nit. acid. Hypertrophic scars have responded to internal medica- 
tion, so there is reason to believe that a keloid, especially if it has not reached 
the height of evolution, may be influenced. Crocker, Neisser and others report 
good results from injections into the growths of ten to twenty minims of a ten 
per cent, solution of thiosinamin in equal parts of water and glycerine or in 
alcohol. 

CICATRIX 

Cicatrix or scar is a new growth of dense fibrous tissue that forms in the 
process of healing by second intention. The new formation is covered 
with epithelium similar to that covering the normal skin, except that it has 
not the intricate and minute surface markings. The surface of the scar is 
smooth or only coarsely marked. Its color is, at first, pink, owing to the 
abundance of blood-vessels and the thinness of the epidermic covering. All 
scars have a strong tendency to shrink, and from the consequent obliteration 
of many of the blood-vessels the color of the scar gradually changes to the 
shining whiteness of dense fibrous tissue. In old scars considerable pigment 
may be deposited. In its contraction, a cicatrix may produce a marked 
deformity, but it is seldom the seat of any pain. 

Eruptions attended by slight loss of substance of the cutis, as the pustules 
of variola, sycosis or acne, may be followed by thin, depressed scars or "pock- 
marks." 

Certain skin lesions, as lupus erythematosus, are followed by an atrophy 
of the cutis that, superficially, resembles a scar. The surface is depressed 
and white, but the lesion is quite superficial and lacks the toughness of a true 
cicatrix. 

Etiology. — Scars are always the result of injury or disease, and corre- 
spond in a large degree in shape and depth to the gaps left in the surface after 
treatment of wounds, or from losses of tissues from diseased processes. Scars 
may therefore be regular or irregular in shape, small or large, flat, elevated or 
depressed. Deep scars are permanent, though they may shrink to smaller 
dimensions. Small superficial scars may in time almost disappear, leaving 
only delicate lines or dots. Scars from burns are apt to contract and form 
uncomfortable or disfiguring constrictions. 

Pathology. — The development of a scar is that of all fibrous tissue. The 




Fig. 123— KELOID 

Patient, a colored woman of thirty-eight years. Duration of disease, ten years. 
Started as a small papule on the back, attended with intense itching. This lesion 
increased in size, and others appeared on breasts, abdomen and back, making twenty- 
one separate lesions. Itching is constant and pain at times severe. X-ray treat- 
ment relieved pruritus'and'pain, but failed to diminish the size of the growths. 




Fig. 124.— CICATRIX 

Patient, a boy of four years. Burned by scalding water. It was necessary 
to graft skin from both thighs by the Thiersch method, which was done by Dr. A. H. 
Bingham. Carron oil and compresses of electrozone were used to prepare the parts 
for operation. The good results are shown in the illustration. 



XANTHOMA AND XANTHOMA DIABETICORUM 168 

wound or ulcer is gradually filled in with a soft, red, granular flesh known as 
granulation tissue. Granulation tissue is composed of loops of blood capil- 
laries surrounded by multitudes of round cells. As tbe granulation tissue 
increases, the lower layers are successively converted into fibrous tissue. When 
this growth reaches the surface of the wound, the surrounding epithelia pro- 
liferate and grow inward over the new fibrous tissue. The advancing epithelia 
are recognized as a circle of bluish-white "skin" around the margin of the 
wound. The upper layers of the cicatrix develop into a papillary body, with 
short, irregular papillae. The cicatrix contains no glands, follicles or fat 
tissue; but. in several instances, Unna has found newly grown elastic tissue 
in a scar. 

Diagnostic Significance of Scars. — The nature of the previous patho- 
logical process may sometimes be surmised by the appearance of cicatrices. 
Scrofulous ulcerations of the skin usually leave disfiguring, linear or irregular, 
and often extensive scars. Lupus cicatrices may also be irregular or uneven 
and disfiguring, though usually they are superficial. The scars from syphilis 
are often delicate and smooth, slightly depressed, sharply defined, but van- in 
shape, depth and extent, and for a time they have a reddish pigmentation, 
which is characteristic. 

Treatment. — Scar formations may be in a measure controlled by indi- 
cated drugs, by skin grafting, by reducing too exuberant granulations with 
caustics, and sometimes in the more extensive formations by surgical measures 
to prevent adhesions and contractions. After cicatrization is complete scars 
seldom require treatment; when hypertrophic they may be made sometimes 
to undergo a partial involution by internal medication. Small superficial 
scars are said by Heitzmann to be greatly improved by the long and frequent 
internal use of oil, such as castor or cottonseed, in doses of three to twelve 
drops. Radiotherapy by absorption of the scar tissue, has produced a softer, 
thinner and smoother scar than the original. Injections of thiosinamin have 
been used as detailed under keloid. Among drugs believed to act on scar tissue 
see Cal. fluor., Fluor, acid, and Graphites. 



XANTHOMA AND XANTHOMA DIABETICORUM 

(Xanthelasma; Fibroma lipomatodes; yitiligoidea.) 

Xanthoma is a new growth consisting of opaque, yellowish plaques or 
flattened nodules. They are most commonly seen upon or around the eyelids. 
The growth is painless and of about the same consistence as the surrounding 
skin. Both the yellow color and the opacity are due to the multitude of fat 
granules that are contained in the tumor, which otherwise consists of fibrous 
tissues, blood-vessels and a variable number of connective tissue cells. 

Xanthomata were formerly divided into several varieties according to the 
form of the lesion, as xanthoma planum, indicating the plaques; xanthoma 



54 XANTHOMA AND XANTHOMA DIABETICORUM 

iuberculosum, the nodular form; and xanthoma tuberosum, a rare variety in 
which the nodules attain the size of a hen's egg or larger. The xanthoma of 
diabetics (xanthoma diabeticorum) formed another and irregular variety. A 
better classification is that of Unna, who distinguishes a xanthoma of the eye- 
lids and a generalized xanthoma ; the first being of very slow growth and strictly 
localized to the eyelids and their neighborhood, the second form being a gener- 
alized eruption that appears rapidly. The generalized xanthoma is more apt 
to be of the nodular form, and the lesions are at first more red and sensitive 
than the dull yellow plaques of the eyelids; but they still have the peculiar 
opacity that allies them clinically with the latter. Generalized xanthoma selects 
especially the elbows and knees, but in some cases it has been observed to appear 
not only on other parts of the skin but also upon the mucous membranes, the 
serous membranes and even the intima of the blood-vessels. As a rule, the 
eyelids escape. Having appeared, the eruption takes on a chronic character, 
lasting for months or years. In time the lesions slowly disappear, leaving no 
mark of their former location. 

Etiology. — Generalized xanthoma not only may occur in the course of 
diabetes, but also may accompany or follow jaundice or other hepatic diseases, 
gout, rheumatism, syphilis, carcinoma, ovarian disease, hydatids and other 
conditions. On the other hand, it may occur in apparently healthy subjects. 
The causes are obscure although some observers believe it is due to embryonic 
and local conditions. Hereditary tendency has been noted in some cases. 

Pathology. — Much has been written of the groups of "xanthoma corpus- 
cles" which are imbedded in the fibrous tissue of the xanthoma lesion. Unna 
declares that these structures are simply dilated lymph capillaries, distended 
with coagulated lymph. The fatty degeneration of the lymph coagulum fur- 
nishes the characteristic masses of fat granules. In the nodule of generalized 
xanthoma there is an entirely different condition. Here there are present 
groups of true connective tissue cells, the centres of which have undergone fatty 
degeneration. Xanthoma lesions are also found in the heart, large veins and 
arteries, liver, spleen, oesophagus and trachea. 

The prognosis of xanthoma of the eyelids is good, in that life is not en- 
dangered. The growth is perfectly benign and the lesions may disappear spon- 
taneously. The same may be said of generalized xanthoma, except that the 
ultimate prognosis will depend upon the nature of the complicating disease if 
any exist. 

The diagnosis of xanthoma of the eyelids is easy. Milium is the only affec- 
tion that could be mistaken for the former. Milia are rarely- larger than a 
pin's head, and on puncturing the epidermis over one its contents can be easily 
pressed out. Xanthoma lesions are often much larger, and on puncture only 
blood and serum can be forced out by pressure. 

Generalized xanthoma is readily distinguished by its more acute develop- 
ment, signs of inflammation and reddish color at first, solid and often nodular 
lesions, and in some cases by its occurrence in the course of diabetes or other 
diseases. 



LIPOMA 

Treatment. — If radical treatment is sought by the patient the smaller 
lesions of the eyelids may be excised with scissors or destroyed by electrolysis; 
when the growths are completely removed they are not likely to return. Caus- 
tics have been employed, but are not to be recommended. A ten per cent, 
solution of corrosive sublimate in collodion painted over the growths has been 
found effective. A better method for larger patches,- and first mentioned by 
Morrow, is the application of a twenty-five per cent, salicylic acid plaster, which 
is worn several successive days. The epidermis is disintegrated by the acid, 
and when the plaster is removed brings away some of the growtli with it; 
other parts are found softened and may be lifted out with a curette. 

When the patient is not urgent for the speedy removal of xanthoma growths 
internal treatment by indicated drugs is not without hope. Special indica- 
tions are to be sought for before selecting a drug remedy. Calc. fluor. and other 
tissue remedies should be studied. The treatment of xanthoma diabeticorum 
is that of glycosuria. 

LIPOMA 

(Fatty tumor.) 

Lipoma is a new growth composed of fat tissue that resembles in gen- 
eral normal adipose. The tumor occurs rather in the subcutaneous tissue 
than in the skin itself. Unna's theory of its formation is that there is a 
local obliteration of the lymphatics resulting in a stagnation of the current 
of fat, which, normally, flows from the fat-producing glands of the skin to the 
cutaneous lymphatics and venous capillaries. The fat, being unable to escape 
by the lymphatics, accumulates in the connective tissue around the blood capil- 
laries and veins, and distends this connective tissue to form the tumor. Lipo- 
mata are soft, flabby tumors, varying in size from a minute nodule to an im- 
mense mass weighing several pounds. The skin covering it is usually normal 
and movable, but may become thickened, reddened and adherent. The tumors 
are either single or multiple, and may grow anywhere on the skin surface ; they 
are usually of slow growth, painless, and can be freely handled without dis- 
comfort. They do not recur after thorough removal. 

These growths are not uncommon and are generally circumscribed; occa- 
sionally they occur as diffuse lobulated elevations of the skin, to which the name 
leontiasis has been given. They may appear at any time of life, but the cir- 
cumscribed tumors are more often seen in adult women, while the diffuse form 
occurs almost exclusively in middle aged men. When combined with other 
congenital new growths, such as fibroma, myxoma, etc., fatty tumors have been 
called ncevus lipomatodes. Occasionally a calcareous deposit takes place in 
fatty tumors and, rarely, they ossify ; in many, if not most, cases they remain 
unchanged for a lifetime. 

The diagnosis of lipoma is never difficult. The soft, lobulated, painless 
tumor, covered by the normal skin, is too characteristic to give room for error. 



456 MYOMA— NEUROMA 

Treatment. — Non-interference is the rule unless some special reason 
exists for their removal. As the lymphatics are cut off from the growths, 
excision is probably the only effective mode of treatment. This is a simple 
procedure when the tumors are small, but may be difficult or unwarranted 
when they are very large or diffuse. Baryta carb. or Baryta iod. may be admin- 
istered. 



MYOMA 

The myoma of the skin is a rather rare new growth composed of invol- 
untary (non-striated) muscle fibres, with which there is always inter- 
mingled a quantity of fibrous connective tissue. "When the connective 
tissue is abundant they constitute myo-fibromata; when new blood-vessels 
are large they form angio-myoma, or, when the lymphatics are involved, they 
are called lymphangio-myoma. The tumor is apt to occur in situations where 
involuntary muscle fibre is normally abundant, as the scrotum, the labia and 
the nipples? Occurring elsewhere in the skin, they grow from the minute 
strips of muscle fibre constituting the erectores pilorum. 

The tumors appear as slowly growing nodules, pink in color and varying 
in size from a pin-head to a hazel-nut. They are firm to the touch and usually 
painless and insensitive, though the entangling and compression of the sensory 
nerve fibres in the slowly growing tumor may give rise to acute pain or cause 
the nodule to become very sensitive to touch. They may be either single or 
multiple, sessile or pedunculated; occur at any age, but are more common in 
advanced age and in females more often than in males. Myomata are benign, 
and. except in a few instances, they have not returned after removal. 

The diagnosis of myomata is not always possible. Small, isolated, slowly 
growing tumors, without tendency to involve the glands or neighboring tissues 
or to ulcerate, and unattended with constitutional symptoms, are indications 
of myoma. But a positive diagnosis may require a microscopical examination 
of the growth. 

Treatment. — This consists in excision if called for by pain or other suffer- 
ing ; or by remedies known to have an affinity for muscle tissue or are indicated 
by subjective symptoms. See Cal. fluorica. 



NEUROMA 

Strictly speaking, the term neuroma should be confined to new growths 
composed entirely or almost entirely of nerve fibres. Practically, the word has 
been used to indicate any benign tumor that grows on or in connection with 
a nerve trunk, or one which was associated with considerable pain. It is 
desirable to limit the meaning of the word to the true neuromata, which are 
almost always a consequence of an injury to the affected nerve. These tumors 



ANGIOMA 467 

may be only as large as a pin-head and rarely exceed the size of a hazel-nut, and 
are imbedded quite deeply in the true skin. They are composed of nerve fibres, 
principally of the medullated variety, with a certain amount of supporting 
elastic, connective and fibrous tissue. The neuromata are rare tumors, the 
best known being the "amputation neuromata" that grow from the nerve trunks 
in an amputation stump. The tumor is often, but not always, painful ; in fact, 
pain and exquisite sensitiveness are the principal clinical features. These may 
be slight at first and slowly increase in severity for months or years, and the 
pain may assume a continuous or paroxysmal type. 

Plexiform neuroma is a rare variety of neurofibroma in which the new 
fibrous formation develops a thickened and tortuous bunch of nerve cords 
instead of forming a distinct tumor. (See Neurofibroma.) 

So-called tubercular dolorosa subcuianea consists of deeply seated nodules, 
mostly situated on the extremities, less often on the scrotum, face and breasts, 
and are sensitive to pressure. They are usually single, rarely multiple, and are 
most often seen in females in adult life. They grow very slowly, are movable 
under the skin and do not return if removed. 

Neuroma may be single, or multiple and disseminated, in almost any 
region of the skin, but show a predilection for the extremities and buttocks. 

Etiology. — The causes of neuroma probably include some predisposition 
and a local exciting irritation or slight traumatism. They may be present at 
birth or begin in childhood, but are more frequently seen in the active period 
of life — between the twentieth and fiftieth year. Sometimes they occur in two 
or more members of a family, seeming to show hereditary influence. Vir- 
chow thinks persons suffering from tuberculosis are particularly subject to the 
disease. 

Diagnosis. — Small, very slowly growing, partially movable, painful, sensi- 
tive and deeply seated growths in the skin are diagnostic of neuroma, but a 
positive exclusion of other growths cannot always be made without a histo- 
logical examination of the tumor. 

Prognosis. — Neuromata do not endanger life, but when attended by severe 
pain may exhaust the nervous endurance in some degree. Usually the more 
painful growths can be removed and thus afford relief. 

Treatment. — Other than surgical methods of relief may be of little avail, 
but a predisposition or some clue as to causation may point to an internal 
remedy, like Cal. fluor and Fluor, acid. 



ANGIOMA 

Under this head are included new growths composed of blood-vessels and 
of lymphatic vessels. The former occur in a number of clinical forms and are 
much more common. The latter will be considered under lymphangioma. 

Naevus vasculosus (naevus flammeus; naevus sanguineus) includes those 
vascular growths which are congenital or develop shortly after birth and 




458 p ANGIOMA 

appear as reddish or bluish discolorations of the skin, due to the presence of 
many dilated blood capillaries. On firm pressure the color disappears, return- 
ing immediately when the pressure is removed. These discolorations form 
the so-called port-wine marks or mother's marks. They are often multiple 
and occur on any part of the body, though most frequently observed on the 
face and neck. They may be very small or cover an extensive surface. The 
nsevus is sometimes raised above the surrounding surface and may present one 
or more soft, compressible nodules. A peculiar form of this lesion is ncevus 
araneus or spider naevus, which consists of a minute central red point from 
which slender red capillaries radiate in all directions. 

Haematangioma. — The blood-capillary tumor or hsematangioma sometimes 
appears as a nodule lying deep in the skin, slowly enlarging to the size of a 
hazel-nut. The overlying skin may be normal or purplish. Like simple 
angioma the tumor is compressible, resuming its original size rapidly when the 
pressure is removed. These growths are generally regarded as true angiomata 
as distinguished from nsevi, and may consist of newly formed capillaries (capil- 
lary angioma), or of large, cavernous blood spaces (cavernous angioma). The 
tumor is benign; it may appear at any time of life and is usually single and 
painless, but pressure on the peripheral nerves may excite neuralgic pains and, 
when located on the head, pulsation or murmur of the tumor may be distress- 
ing at times. 

Telangiectasis. — This lesion consists in a dilatation of the blood-capillaries, 
and is usually secondary to other known diseases. Telangiectasis is observed 
in its best development on the nose and cheeks of those affected by rosacea. 
The dilated capillaries appear as fine red lines that branch and interlace over 
the affected surface, or the dilated vessels may form small tubercles. The 
same capillary dilatation is sometimes found around a scar or in connection 
with scleroderma or other condensation of the skin. 

Angioma serpiginisum (Infective angioma; JSTsevus lupus). — This is a 
peculiar and uncommon form of angioma that appears in the form of minute 
red specks arranged to form circles, or gyrate lines where several widening 
circles have coalesced. There first appears a group of red points, which slowly 
enlarges by the appearance of new spots at the periphery. As the lesion en- 
larges it clears in the centre, after the manner of a ringworm. From these 
characteristics serpiginous angioma is supposed to be infective in its nature and 
allied to lupus erythematosus. The minute changes consist in a localized 
dilatation of the capillaries of the papillary body. The lesions are usually 
multiple and appear indifferently on the trunk, head or limbs. 

Angiokeratoma or keratoangioma is a rare eruption, consisting in the 
appearance of small translucent nodules of a red or bluish color and a warty 
or horny surface. The nodules are about the size of a pinhead and have 
occurred on the fingers, palms, soles, scrotum and ears. The lesions are 
formed by a capillary dilatation, with a thickening of the overlying epidermis. 
They seem to be often associated with the variety of dermatitis known as 
chilblains, and are probably due to the same cause. In a single case of my own. 



ANGIOMA !•>'•' 

situated on the scrotum, the patient was subject to cold hands and feet, but 
had never had chilblains. Fordyce has reported a similar case involving the 
scrotum, with the results of a histological study of the growths. 

Etiology and Pathology. — Little is known concerning the causes of 
angiomata. Vascular naavi are probably due to some congenita] defecl permit- 
ting an overgrowth of capillaries in the skin. Acquired dilatations of the 
blood-vessels may arise from long continued or frequently repeated hypersemia 
of the skin, due to general or local conditions. When associated with other 
growths the capillary enlargement may be due to local obstructions of the 
circulation by the latter. No definite cause is known for the few cases so far 
reported of serpiginous angioma. Angiokeratoma has been attributed to cold 
and has been thought to be allied to chilblains, but the disease occurring on the 
scrotum proves that cold is not the only exciting factor. Anatomically the 
angiomata are due to dilatation and new formation of the venous and arterial 
capillaries in the upper portion of the derma associated with a new formation 
of connective tissue which constitutes the framework of the new growth. 

Diagnosis of the Angiomata. — Vascular nmvi can be recognized without 
difficulty. They may be distinguished from the acquired form, or telangiecta- 
sis, by their congenital history and the lack of visible capillaries except at the 
margin. The differentiation is not important. Hamatangiomatous tumors 
are usually free from pain or sensitiveness; they disappear on pressure, but 
quickly refill as pressure is removed, and sometimes they pulsate. A cavernous 
angioma with a firm and dense capsule may be difficult to distinguish from a 
fibroma, but the latter is much more likely to be multiple. The dilated capil- 
laries, single, interlaced or formed into tubercles, are pathognomonic of telangi- 
ectasis. The extremely rare serpiginous angioma can always be recognized by 
its peculiar clinical course. Angiokeratoma is distinguished by its minute red 
or purplish warty elevations, the color from which partly disappears on pres- 
sure, by its frequent association with chilblains and persistency without treat- 
ment. 

Prognosis. — The course of the angiomata is uncertain. Some congenital 
growths remain stationary, some diminish or disappear with age, others 
may pursue an opposite course and increase steadily in size or change from 
a flat birth-mark to tumor-like growths. The pulsating or cavernous angioma 
may be accidentally ruptured or ulcerate and alarming or fatal hemorrhage 
result. Telangiectases can be cured only by a removal of the causal condi- 
tions; they are not dangerous to life. Serpiginous angioma and angiokera- 
toma may last indefinitely without treatment, but they are probably attended 
with little or no danger of serious results. 

Treatment. — The small vascular naevi in young children should not be 
meddled with locally other than occasionally painting them over with collo- 
dion, which produces slight compression on the vessels. These growths often 
disappear and may be assisted to do so by remedies to be mentioned later. 
If disfiguring or spreading, local methods may be employed early. 

Electrolysis employed in the same manner as for the removal of super- 



460 ANGIOMA 

fluous hair is probably the most satisfactory method for the obliteration of 
flat vascular growths. A single needle or a number of needles,, arranged in 
a holder in circles or rows, at least one-twelfth of an inch apart, may be 
used attached to the negative pole of a galvanic battery and inserted through 
the entire thickness of the skin. When carefully done, particularly with one 
needle, the resulting scars are not very conspicuous, or are much less so than 
the naevus sought to be removed; moreover the scars may become less appar- 
ent in time with the aid of internal remedies. The sittings can be repeated 
every few days, according to the effect, as many times as needed, until the 
growth is destroyed or rendered inconspicuous. Often it is wiser not to 
completely remove, but only to greatly modify the color of the mark. Some- 
times capillary points reappear weeks later and need to be destroyed again. 

When electrolysis is employed for the destruction of hasmatangioma the 
needle needs to be introduced obliquely under the tumor and sometimes out 
at the opposite side, or a gold or platinum needle may be attached to the 
positive pole and passed in obliquely in an opposite direction to the needle 
attached to the negative pole, both deep enough to strike the larger vessels 
supplying the growth. 

For telangiectasis the needle need only be introduced just within the 
capillary to be destroyed and the circuit completed until the capillary be- 
comes a white line, as first advised by Hardaway. 

In angioma serpiginosum Crocker suggests the use of electrolysis to 
occlude the superficial blood-vessels in a line just beyond the advancing bor- 
der of the disease. When desired the vascular dilatations of angiokeratoma 
may be destroyed by electrolysis in the same manner as for telangiectasis. 
For elevated nsevi and cavernous angioma multiple puncture with a fine 
galvano-cautery needle at a red heat is sometimes used. No results can be 
determined until the inflammation fully subsides. The author has used in 
the same way a small shoemaker's awl, made red hot in an alcohol flame, 
effectively in one case. 

Phototherapy has been used effectively in a few cases of vascular nsevi. 
When a considerable area is involved or the supplying or composing vessels 
are not very distinct, this method would seem preferable to electrotysis. 

Other local methods of treatment of the angiomata are usually less suited 
or less effective than electrolysis, and consist of excision, compression, cauter- 
ization, injections into the growths, vaccination, multiple scarifications, etc. 

Excision is effective when made outside the line of growth, and is practi- 
cable for small naevi when the incised skin can be coapted, leaving only a 
linear scar. Cavernous angioma may also be excised, but the danger from 
hemorrhage is always possible. 

Compression with an elastic bandage may be effective for flat or small 
elevated nsevi when situated over a bone, affording counter pressure to the 
compress of cork or other substance placed over the growth. Care needs 
to be exercised as to the degree of pressure which can be borne without danger 
to the sound tissues covered by the elastic band as well as the skin over the 
growths. 



LYMPHANGIOMA I'll 

Caustics are sometimes employed for the destruction of superficial nam. 
For this purpose the freshly prepared ethylate of sodium may be applied 
with a glass rod to a small part of the patch at a time so as to produce the 
least scarring. The crust which forms should be allowed to separate spon- 
taneously, while other portions of the growth receive applications at inter- 
vals sufficiently long to avoid exciting too much inflammation. Careful and 
even tattooing with a steel needle dipped in nitric or carbolic acid is some- 
times efficient in partially obliterating superficial naevi. 

Injections into these growths of alcohol, tannin, carbolic acid or other 
irritating substances, while effective in producing inflammation and occlusion 
of the blood-vessels, is always attended with danger of direct entrance into 
the circulation and fatal results therefrom. 

Vaccination upon the site of a nsevus is only practicable for the oblitera- 
tion of small growths situated in unexposed parts. The local effects of vac- 
cine inoculation are not under control, and the scar may be more unsightly 
than the birth-mark. 

Among other methods which have been recommended, mention may be 
made of multiple scarifications made obliquely through the skin as advocated 
by Squire; subepidermic breaking up of the growth by passing a cataract 
needle through it in several directions from a single point of entrance as 
suggested by Marshall Hall; passing threads through the growth to excite 
inflammation and methods of strangulation of the vessels with hair-lip pins 
or ligatures. These are all inferior, less certain or more dangerous than 
other measures named, especially in comparison with electrolysis. 

The internal treatment of the angiomata is uncertain in results, but there 
are drugs which seem to have a marked affinity for the capillaries, and have 
apparently proved curative in some cases of vascular naevus and for secondary 
telangiectasis. Among such drugs see indications for Cat. fluor., Cundurango 
and Lycopodium. 

LYMPHANGIOMA 

(Lymphangiectasis; Lymplwrrhagica pachy derma.) 

Lymphangiomata are tumors composed of newly formed lymph vessels. 
Clinically, no sharp line can be drawn between lymphangioma and lymphan- 
giectasis, the latter being a simple dilatation of the lymphatics. Simple 
lymphangiomata appear preferably about the face and neck as deep-seated and 
sometimes warty nodules of various sizes, rarely exceeding half an inch in 
diameter. The overlying skin is normal or pinkish, and though their walls 
are thick the nodules may have a translucent appearance. They occur in 
groups often with sound skin between the lesions. When punctured a drop 
of clear or turbid lymph exudes or the lymph may be mixed with blood, as 
a combination of blood and lymphangiomata is not uncommon. It is proba- 
ble that most of these tumors are congenital and should be considered a> 



462 LYMPHANGIOMA 

lymphatic nsevi. They pursue a non-inflammatory chronic course, spread 
at the periphery, and are apt to recur if removed. 

At times lymphangioma will form as a hazel-nut' or walnut-sized sub- 
cutaneous tumor that, clinically, resembles a lipoma. When removed it is 
found to consist of a spongy tissue, which constitutes a cavernous lymphatic 
system. 

Dilated lymphatics of the skin may be superficial or deep; when super- 
ficial the swellings may be agglomerated or isolated, very minute in size, 
up to a pea or larger. The deep varieties can sometimes be felt better than 
seen. Both varieties are apt to rupture sooner or later and discharge lymph. 
There are several peculiar varieties of lymphangioma that are more within 
the province of the surgeon than the dermatologist. These are macro glossia, 
or congenital enlargement of the anterior portion of the tongue; macrocheilia, 
a similar enlargement of the lip, and hygroma colli, a cystic formation on the 
neck, classed as a cystic lymphangioma, and probably is an immensely distended 
cavernous lymphangioma. Under the name of lymphangioma tuberosum 
multiplex, Kaposi reported a case of this disease which has since been shown 
to be a form of "multiple benign cystic epithelioma" (q. v.). Another lesion 
to which this name has been applied was described by Pospelow. There were 
small multiple nodules which, on incision, ejected a turbid fluid, some colloid 
substance and a drop of blood. The tumors were simply cavernous lymphan- 
giomata of peculiar distribution. The term lymphangioma circumscriptum 
(lupus lymphaticus; lymphangiectodes) has been applied to a form in which 
the characteristic lesions are small, deep-seated, pin-head to pea-sized vesicles. 
These may be few or many, grouped or scattered, and are frequently surrounded 
by inflammatory areas. If the irritation be long continued or repeated, indu- 
ration and thickening of the true skin ma)' develop, causing a local elephan- 
tiasis. 

Etiology. — The causes of lymphangioma and lymphangiectasis are not 
fully known. It is probable that most cases are due to congenital defects and 
began in infancy or childhood ; some to local injuries or irritations, and others 
to obstruction of the cutaneous vessels from the products of various diseases. 
Why these factors produce disorders of the lymph structures in one instance 
and not in many similar cases is unsolved, but leads naturally to the supposi- 
tion that the efficient cause is hidden. Affections of the lymphatics are more 
common in the tropics and among halfbreeds. 

Diagnosis. — Its origin in childhood, slow, progressive course, the small, 
deep-seated, thick-walled and sometimes warty vesicles, usually confined to 
one region, are diagnostic features, which, however, may require a micro- 
scopic examination of the contents of a lesion to make the recognition posi- 
tive. From other vesicular affections lymphangioma vesicles may be dis- 
tinguished by their thicker walls, long duration without inflammation and 
by a discharge of lymph. From groups of warts, by their vesicular character. 

Lymphangiectasis may be mistaken for chronic abscess or varicose veins. 
To make positive differentiation it may be necessary to wait for a discharge 



N.EVUS PIGMENTOSUM 4(13 

of lymph or to withdraw some for examination. It may be helpful to re- 
member that lymphatic dilatation is always secondary, though the antecedent 
condition is not often plain, and its most common form is elephantiasis. 

Treatment. — This is largely local and operative in most cases. When 
the preceding causes of the disease are known and present, remedial methods 
should be directed to their removal, if that be possible. The first question 
to decide is, shall the growths be interfered with at all ? If so, the lymphan- 
giomata may be destroyed by caustics, by electrolysis or excised. The electro- 
cautery or thermocautery is said to give the best results, as the parts need 
to be deeply destroyed to produce any lasting benefit. The scarring which 
results is likely to be considerable, and electrolysis or excision is to be pre- 
ferred for exposed surfaces. A needle attached to the negative pole of a 
battery can be inserted deeply into the vesicles, and the current of from six- 
teen to twenty cells allowed to pass long enough to produce thorough coagula- 
tion of the contents. Excision to be effective needs to be carried well beyond 
the growth and is hardly adapted for the removal of large patches. 

Dilated lymphatics may be treated in the same way as varicose veins, by 
support with elastic bands, etc. If the number and size of the lymph varices 
is small, electrolysis may be employed as already described. In chronic cases, 
after the tissues have given way to fistula? and ulceration, deep cauterization 
with chloride of zinc has proved efficient. Aggravated cases attended with 
debilitating lymphorrhagia may demand amputation as the only way of relief. 

Internal treatment, physiological and pathogenetic, must be based on 
general indications found in each case. See Cal. phos., Carbo. veg., Hydro- 
cot., Pet., Phos., Sul., Vipera. 



NJEVXJS PIGMENTOSUS 

(Mole; Pigmentary Mole.) 

Moles are growths or marks that are characterized by being present at birth 
or appearing in the early months of life by the presence of an excess of pig- 
ment and by their persistence practically unchanged through life. Sometimes 
the mole consists of a small brown or black spot, with no elevation of the skin ; 
more often the skin is raised to form a rounded, sessile tumor, brown in color 
and varying in size from a minute point to a diameter of half an inch. The 
mole may be hard or soft ; its surface may be smooth, or it may be finely cor- 
rugated or warty, ncevus verrucosus. On some moles, there is a thick growth 
of hair, constituting the ncevus pilosus. In others, there is a complete absence 
of pigment, forming the so-called " white mole." Moles may exhibit a linear 
arrangement suggesting a nervous influence (linear ncevus; ncevus nervosum). 
All the pigmented moles, including the ncevus pilosus, are classed as naevus 
pigmentosa. Moles may be single or multiple and are situated more often on 
the face, scalp, neck and less frequently on the trunk and extremities. Among 



464 ACANTHOSIS NIGRICANS 

the soft nsevi, Unna classes many small, fleshy, sessile or pedunculated growths 
that correspond to moles in their appearance in early life and their persistency 
with little change. 

Etiology and Pathology. — The exact cause of moles is unknown. Most 
cases are congenital and occur equally in both sexes. Anatomically, there are 
two classes of moles: first, those in which the pigment of the skin becomes 
hypertrophied ; second, those in which the epidermis is always hypertrophied, 
together with some hyperplasia of papillae, vessels, glands and follicles. There 
is probably a tropho-neuritic influence present in all cases. 

Treatment. — Moles may be removed by operative methods and with caus- 
tics, but the resulting scars may be as disfiguring as the original pigmentation. 
The liability to scar formation should be fully explained to patients who solicit 
radical treatment. When small they can be removed by excision and leave 
only_a linear cicatrix or with the electric knife; when warty, by the dermal 
curette, or they can be destroyed with electrolysis by multiple puncture or 
transfixation. Sodium ethylate is probably the best caustic application for 
moles, as it does not penetrate deeply into the tissues ; it should be applied with 
a glass rod and carefully limited to the part to be destroyed; nitric or strong 
acetic acid may be applied in dots with a fine pointed glass rod holding a 
minute drop of the acid. Hairs growing from a mole are often more dis- 
tressing than the pigmentation; hairs may be permanently removed by elec- 
trolysis, as described for the removal of superfluous hair in another section. 
Radiotherapy has been used with indifferent success, while phototherapy has 
succeeded in a number of cases. 

In children, and when moles show a tendency to multiply at any age. an 
indicated remedy should be given. Compare Cdl. carb., Cundurango, Fluor, 
acid, Lye, Nit. acid and Petroleum. 



ACANTHOSIS NIGRICANS 

In all some thirty cases of this condition have been reported by European 
observers. Pollitzer and Janovsky related the history of three cases in which 
there were papillary, wart-like growths which could hardly be classed as 
ichthyosis, verruca or nsevus pigmentosus. In two of the cases the mucous 
membrane of the mouth was involved. The coloration varied from a gray to 
a dark brown or blackish tinge, situated on the face, neck, back of hands, 
fingers, axilla and genital surfaces, while the verrucous growths were chiefly 
found in the axilla? and groins. Two of the cases developed rather suddenly, 
the other gradually. There were no local sensations to speak of in or about 
the lesions. 

Etiology and Pathology. — "Women are affected more often than men, but 
not at any particular decade of life. No causes are known, though in two cases 
one had been exposed to extreme cold, and the other more or less habitually to 
the severe heat of a pottery furnace. Theoretically, it is possible that vaccina- 



MULTIPLE BENIGN TUMOR-LIKE NEW GROWTHS Wfi 

tion effects might be a predisposing factor, and in some instances, it may be 
related to carcinoma. Pathologically, dilatation of vessels and lymphatics in 
the papillary and sub-papillary layers, increase of pigment cells, thickening of 
papillae and epidermis, and elongation of rete-pegs, have been noted. 

Treatment. — Locally, the same methods as advised under naevus pig- 
mentosus are called for when feasible, but little effect has been noted. Th uja 
and Aurum mur. might be studied. 



MULTIPLE BENIGN TUMOR-LIKE 
NEW GROWTHS 

As the name suggests, this somewhat obscure and rare affection consists 
in the appearance of many small nodules in the skin that exhibit the per- 
sistency and innocent character of the benign tumors. In the case recorded 
the tumors could be pressed into the skin, leaving small temporary pits. Of 
this disease little is known of its histopathology other than that an absence of 
elastic fibres and an overgrowth of glandular tissue were found in the growths. 
Nothing is known regarding its etiology or cure. Schweninger and Buzzi 
first described this condition as it occurred on the back, arms and chin of a 
young woman. 



COLLOID DEGENERATION OF THE SKIN 

(Colloid milium.) 

Colloid degeneration of the skin or colloid milium is a rare and compara- 
tively unimportant lesion, which usually occurs on the face, especially on the 
forehead. The disease consists in the appearance of numerous pinhead- 
sized lesions of a bright lemon-yellow color and a peculiar translucency 
resembling a drop of serum. When one is incised the contents may be 
squeezed out as a yellow, gelatinous substance. Microscopic investigation has 
shown that this lesion does not involve the sebaceous glands, but that it is a 
localized colloid degeneration of the corium. There are no subjective symp- 
toms and the disease does not seem to be at all related to the general health. 

Etiology. — The causes are unknown. In the very few cases reported 
nearly all had been subject to exposure to the weather, and two had suffered 
from headaches or neuralgia. 

Diagnosis. — In the diagnosis of these growths milium, hydrocystoma. xan- 
thoma and benign cystic epithelioma may need to be excluded. Milium lacks 
the vesiculoid look of colloid degeneration and its sebaceous contents can be 
easily demonstrated. Hydrocystoma occurs only in hot weather or from ex- 
posure to moist heat, and on pricking one of its lesions a clear liquid will 



466 LUPUS ERYTHEMATOSUS 

escape quite different from the gelatinous product of colloid change. Xan- 
thoma is usually confined to the neighborhood of the eyelids; its lesions are a 
deeper yellow and never simulate the vesicular type like colloid growths. In 
multiple benign cystic epithelioma the lesions^are disseminated over the body, 
often congenital in origin, and are seldom yellowish in color. 

The treatment consists in removing the growths by incision and express- 
ing their contents, or removal with the curette, and sometimes perhaps by 
electrolysis. Internally, physiological and drug treatment should be given on 
the needs of each case. Drug remedies believed to influence colloid meta- 
morphosis may be thought of, such as Baryta carb. or B. iodide. 



LUPUS ERYTHEMATOSUS 

{Lupus super jicialis ; L. sebaceous; L. erythematodes; Ulerythema (TJnna), 

etc.) 

Definition. — Lupus erythematosus is a disease of adult life character- 
ized by the appearance of reddened, scaly patches which persist for many 
months or years and terminate in areas of atrophy that resemble thin, de- 
pressed scars. 

The most common location of this eruption is upon the bridge of the nose 
and the adjoining surface of the cheeks, where the red patch often assumes a 
symmetrical form resembling a butterfly with outstretched wings, whence the 
name butterfly lupus. The eruption appears as a small, dusky-red spot, 
slightly elevated above the surrounding skin, which soon becomes covered with 
yellowish, horny scales that are quite closely adherent to the surface. When a 
scale is removed there is seen upon its under surface a small, peg-like projec- 
tion that corresponds to a small pit in the skin. From the naked eye appear- 
ance Hebra concluded that the pits were the mouths of hair follicles and 
sebaceous glands, and that the plugs were composed of dried sebaceous matter. 
From microscopical and, it would seem, more exact observation, TJnna declares 
that the scale is composed of the thickened stratum corneum that has extended 
down into and filled the hair follicles, forming the pegs. 

A telangiectic form has been described characterized by persistent, cir- 
cumscribed redness, which is found to be due to dilated blood-vessels and is 
attended with marked thickening of the skin. The degree of redness varies 
considerably in different cases, but it usually has a characteristic violaceous tint. 
Itching or burning may occasionally be felt, but there is never any moisture 
unless complicated with eczema, which is rare. 

The lupus lesion gradually increases to the size of a quarter or silver dollar, 
or even larger. When examined closely the reddened patch is found to be made 
up of many small, flattened papules that have coalesced. Sooner or later a pro- 
cess of atrophy sets in at the centres of the individual papules, so that the 
surface of the lesion is sprinkled with small, pinhead-sized depressions that 




Fig. 125.— LUPUS ERYTHEMATOSUS 



Patient is a man of fifty-eight, in good general health, except a periodic head- 
ache for many years, which occurred every one or two weeks, attended with throb- 
bing and often with a late morning aggravation. Duration, three years. A few weeks 
ago the lesion consisted of a violaceous patch about the size of a silver half-dollar, 
with an elevated border, small adherent scales, and several blackish crusts said to 
have been the effect of some local application. Cured with natrum mur., twelfth 
decimal. The illustration here is from a photograph taken when the patch was 
about half clear, and shows the atrophic skin once the seat of the disease. 




Fig. 126.— LUPUS ERYTHEMATOSUS 



Patient is a female of thirty-one years. Duration of disease, six 
years. The elongated patch shown in the illustration was formed 
by the coalescence of two primary patches along the interparietal 
region of the scalp. The typical violaceous color remains at the 
borders of the lesion, while the centre is becoming atrophic. Rhus 
tox, third decimal, hastened the cure. 



LUPUS ERYTHEMAT0S1 B 167 

become white and smooth like minute cicatrices. The atrophic process con- 
tinues, and, after the lapse of years, the disease may cease to advance al the 
borders, the redness disappears and the site of the lesion is marked permanently 
by a depressed, eieatrix-like, shining, atrophic area. 

Besides the nose and cheeks, lupus erythematosus is sometimes found upon 
the scalp, when it leads to permanent baldness; also on the ears, and, less fre- 
quently, upon the limbs and trunk. The yellowish crust is often absent. An 
acute and generalized eruption of erythematous lupus, with high fever and 
typhoid symptoms, has been described. It is a fatal disease and rarely, if ever, 
seen in this country. Crocker mentions a nodular form of lupus erythematosus, 
in which growths from a hemp-seed to a bean in size persisted for a Long time 
with little tendency to central involution, but in one case resulted in atrophic 
scarring. 

The course of lupus erythematosus is tisually very slow, sometime- sta- 
tionary for a long time, and often lasting for years — ten, twenty, or even longer. 

Etiology and Pathology. — The cause of the disease is unknown. Bes- 
nier and other French dermatologists still maintain the tubercular nature of 
lupus erythematosus and its close connection with the undoubtedly tubercular 
eruption, lupus vulgaris. This claim is based on such clinical evidence as the 
frequent occurrence of the disease in certain tuberculous families, and in those 
who are constantly 7 associated with tuberculous cases. It is also claimed that 
the erythematous lupus sometimes passes into the tuberculous form. The 
majority of dermatologists have relinquished this claim, since lupus erythema- 
tosus lacks the histological structure of tubercle, since careful and repeated 
search has failed to reveal the tubercle bacillus and since inoculation experi- 
ments on animals have been fruitless; whereas the tubercular nature of lupus 
vulgaris has been repeatedly proved by all these tests. 

This disease usually develops in the third decade of life and attacks 
females twice as often as it does males. It has been known to follow acne 
seborrhceic dermatitis, variola, erysipelas, and undue exposures to sunlight 
and other thermal agencies or to frequent attacks of permo. 

As to the histology of the lesion, Hebra's suggestion as to the sebaceous 
nature of the overlying scale has led many investigators to discover changes in 
the sebaceous glands; but the more careful work of Urma has shown that the 
sebaceous glands take no active part in the disease, and that the scales and pegs 
are composed of the thickened stratum corneum that fills the atrophied hair 
follicles. The flattened papules, like the syphilitic papule, are due to an 
infiltration of the cutis with round cells (plasma cells) ; and the subsequent 
atrophy consists in a softening and absorption of the fibrous cutis, atrophy of 
the follicles and glands and thinning of the epidermis. The essential changes 
are the infiltration and subsequent atrophy of the cutis, whereas the scale 
formation is only incidental and, in many eases, does not occur. Unna substi- 
tutes for the name, lupus erythematosus, the more descriptive term, ulerythema 
centrifugum.. Robinson claims that the primary lesion is focal in character 
and may be situated in any part of the corium, and when developed constitutes 



468 LUPUS ERYTHEMATOSUS 

a new growth which is reticular in character and closely associated with the 
lymphatic system. In substance he believes the condition is a " local infec- 
tive process — a granuloma." 

Prognosis. — As a rule, lupus erythematosus is not associated with other 
diseases. Though cases are recorded in which the patient died of disease of 
the heart, lungs or kidneys, any close relation of these diseases with the lupus is, 
at least, questionable. The eruption usually persists for a number of years, 
either increasing' or remaining stationary, and finally either with or without 
treatment the color fades, the scale disappears and the depressed atrophic sur- 
face alone remains. Apparent sudden improvement or blanching may take 
place by a temporary decrease of blood in the capillaries of the part, but, in a 
few days, the lesion usually assumes its former disfiguring color. Occasionally 
a very superficial patch of comparatively short duration may disappear without 
scarring. Barely lupus vulgaris develops during its course. 

Diagnosis. — The violaceous color, adherent scales with the minute pro- 
jections underneath, found upon removal, occurring in adult life and often 
exhibiting some atrophic spots, are usually sufficient to determine the existence 
of lupus erythematosus. It may be closely simulated by eczema, psoriasis, 
lupus vulgaris, tricophytosis and syphilis. 

An eczema patch is not so sharply defined, is frequently moist and attended 
with pronounced itching; its scales or crusts do not have prolongations on the 
under side ; it is more rapid in its course and never leaves scars. Occasionally 
outbreaks of eczema may complicate a lupus. 

Psoriasis is not common on the face without positive signs of the disease 
elsewhere on the surface. Its scales do not fit into pit-like depressions, nor 
does it produce scars, or, as a rule, cause baldness, when situated on the scalp. 

Lupus vulgaris, as a rule, occurs before adult life, is rarely symmetrical, 
is characterized at times by the presence of jelly-like tubercles, often ulcerates 
and leaves disfiguring scars. A ringworm patch is unusual in adult life; it 
does not show the characteristic scales or scars of lupus erythematosus, and a 
microscopic examination of the scales of ringworm will show the presence of 
the trichophyton fungus. A scaly sijphilide may closely resemble lupus in 
shape and general appearance, but the lesions are more rapid in their evohition ; 
they are usually associated with other signs of syphilis, and do not exhibit the 
peculiar scales projected into the skin of erythematous lupus, and are much 
less hyperaemic. 

Treatment. — Two local conditions — hyperseniia and superficial cell infil- 
tration — are to be overcome in curing lupus erythematosus. All influences 
which tend to keep up or increase these conditions must be eliminated. The 
diet of plethoric subjects needs to be cut down, especially as regards meats and 
other stimulating food. Fresh vegetables, fruit and very moderate use of meat 
is the best diet for most cases in the author's experience. Due allowance must 
be made, however, for differences of habit, occupation and especially for idiosyn- 
crasies in each case, but the rigid avoidance of all articles which are known to 
aggravate the redness must be enforced. Systematic care of the whole skin by 



LUPUS ERYTHEMATOSUS Wfl 

a daily bath and frictions adapted to the case in hand is helpful. The same 
may be said of physical exercise. 

Although the subjects of lupus erythematosus usually seem to be is good 
general health, careful inquiry will nearly always reveal some indication on 
which an internal remedy may be selected. When the symptoms have been 
clear and characteristic of some drug, I have seldom failed to see a good effect 
produced by it on the diseased skin. Natrum mur. and Rhus tox. have been 
found most often indicated, but these do not stand alone nor does the list 
below comprise all the drugs among which may be found the nearest similium, 
but only those which experience has shown to be of benefit. 

Local measures are usually relied upon for the cure of lupus erythematosus, 
but the patches of - this disease are so easily stimulated into activity that great 
care is necessary if local applications are used at all. When a well indicated 
internal remedy is found in a given case I believe it is wise to forego all applica- 
tions until internal treatment has proved ineffective. Some of my cases have 
responded almost immediately to indicated drugs, especially to the two named 
above, without the aid of external applications. If local methods are deemed 
necessary they may be employed chiefly for a mechanical effect in the removal 
of hard and irritating scales; for a pathogenetic effect to stimulate resolution, 
or they may be operative for a like purpose. 

Phototherapy while not achieving the notable results in the treatment of 
erythematous lupus that it has in lupus vulgaris, has yielded good results in 
cases of a subacute nature with an excessive vascular development. Radio- 
therapy seems better suited for those cases in which deeper involvement of the 
cutis is noted, the follicles and glands sharing in the process and infiltration 
being marked. In a number of cases a combination of both photo- and radio- 
therapy has worked well when neither alone seemed to accomplish the end in 
view. Bisserie records thirty-three cures in a total of sixty-two cases of lupus 
erythematosus treated by the high frequency currents. It is our personal 
experience that the high frequency currents will often complete a cure started 
by the Eontgen-rays, and Leredda believes they should precede phototherapy. 
Danlos recommends radium for this disease; our results have been absolutely 
negative. 

Simple mechanical methods may consist of frequent anointing of the 
plaques with cold cream, olive oil, sweet almond oil or other non-medical fat, 
and occasionally rubbing them with tincture saponis camphorata. This keeps 
the surface free of scales and has only a moderately stimulating effect, which 
should be allowed to fully subside before the tincture of soap is again applied. 
If too great aggravation is obtained ordinary soap and water may be employed 
for cleansing, only the mechanical removal of the scales being sought for in 
this way. The reaction following from an occasional and moderate stimulation 
(aggravation) is, however, often beneficial in promoting resolution. 

In some cases a more decided pathogenetic effect needs to be produced. 
Green soap is often chosen for this purpose, and preferably dissolved in alcohol 
— two parts to one part of alcohol. This is rubbed briskly over the patch 



470 LUPUS ERYTHEMATOSUS 

until it removes the scales ; the inflamed surface which follows from the appli- 
cation can be dressed with simple ointment until the resulting crust is shed, 
then the soap can be reapplied. If the reactions from this treatment show 
no succeeding improvement in the eruption after a few trials it should be dis- 
continued, as, though very effective in some instances, it appears equally inef- 
fective or harmful in others. Among a multitude of applications which have 
been recommended may be mentioned tincture of iodine ; iodide of glycerine; 
solution of caustic potash, one part to eight to twelve parts of water; naphthol, 
one per cent., or resorcin, five to fifty per cent., or sulphur, ten to thirty per 
cent. . or salicylic acid in five to ten per cent, in solution or ointment ; solution 
of carbolic acid, saturated or diluted with two to four parts of water; ammoni- 
ated mercury ointment and pyrogallic acid in five to ten per cent, ointment. 
Some of these, such as iodine and salicylic acid, may be used in collodion with 
greater effect. Oxidized pyrogaltol, one to two per cent., in acetone collodion 
is recommended. Others are serviceable in plaster form, especially resorcin, 
naphthol and mercury. Whatever local agent is employed, the stimulating 
effect should not be carried too far, but allowed to subside at intervals, and 
often with the aid of soothing and protecting applications. The strong chemi- 
cal caustics should never be used, and operative methods are only justified when 
the disease does not yield to other well directed measures, or the lesions are 
hypertrophic and resistant. It is to be remembered that lupus erythematosus 
is a benign affection unattended with danger to life, and that there can be little 
or no excuse for the employment of powerful agents likely to leave scars more , 
persistent and perhaps more objectionable than the primary disease. 

Superficial scarification made in two or more directions and over only a 
small surface at one time is probably the best operative method. The bleeding 
which follows may be arrested by pressure, or, if necessary, by the application of 
carbolic acid, one part to four parts of water. Afterwards mild antiseptic oint- 
ments or plasters may be employed during the healing process, and, meanwhile, 
another section of the patch can be treated in like manner. Curetting or 
scraping away the infiltrated tissue with a sharp spoon is a severe method which 
is likely to result in considerable scarring, but is sometimes effective in intract- 
able cases. The subsequent treatment of the surface is the same as after 
scarification. Both of these methods induce fibrous change and are therefore 
in a line with nature's method of obliterating the disease. 

Electrolysis, the galvano-cautery and the thermocautery have not proved of 
enough advantage over other methods to warrant the production of more or 
less disfiguring scars, which must always follow their efficient employment. 

For internal remedies see indications for Apis, Fluor, acid, Hydras., Ey- 
drocot., Kali mur., Natrum mur., Rhus tox., Pet., Sepia. 



MYXCEDEMA 47 1 

MYXCEDEMA 

(Cretinoid oedema.) 

Myxoedema is an infrequent disease characterized by a thickening of 
the skin, atrophy of the thyroid gland and a progressive failure of the 
bodily and mental power. In the skin the disease commences upon the lace, 
giving it a swollen, cedematous appearance, the so-called moon-face, which, to 
the trained eye, is typical of the disease. This swelling generally extends to 
other parts of the body. The swollen tissue is firm and does not pit on pres- 
sure. Its surface is dry and anasmic and over the extremities is sometimes 
livid; the hair falls out, especially from the axilla? and pubis. Together with 
this remarkable change in the skin, there develops a feebleness of body, dullness 
of the special senses and a sluggishness of mind that may increase to imbecility. 

Etiology and Pathology. — The cause of the disease is still obscure. It 
may occur at any age, but is most common in women after middle life. As in 
nearly all cases the thyroid gland has been found atrophied, and as a similar 
stage has been induced by the removal of the thyroid in human beings and 
animals, the atrophy of the thyroid is supposed to be the original lesion. The 
cause of the thyroid atrophy is unknown, but heredity is probably a factor and 
the pathogenesis very like that of sporadic cretinism in which a congenital 
deficiency of the thyroid has been found. Ord states that there is a mucous 
degeneration of the subcutaneous fat and infiltration of the cutis with mucin, 
whence the name myxoedema, or mucous dropsy. , Hun observed that there 
was a general atheromatous endarteritis and it is generally admitted that the 
nervous system is involved, although Charcot's contention that this involve- 
ment is the primary factor may be doubted. 

Diagnosis. — The increase in the volume of the skin in myxcedema may be 
distinguished from dropsical swellings by the absence of pitting on pressure 
and by the absence of primary kidney, heart or other disease resulting in 
dropsical effusion into the skin. Acromegaly can be excluded in the absence 
of enlargement of the bones, chiefly of the hands and feet. No other disease 
is liable to be mistaken for myxoedema if its characteristic symptoms are kept 
in mind. 

Treatment.- — This is always by "thyroid feeding." The desiccated or 
powdered glands given in capsule or tablet form are most convenient for this 
purpose. The dose should be small at first, say. of one grain three times daily, 
and gradually increased up to five grain doses, if needed, or if symptoms of 
thyroidism (rapid pulse, shortness of breath, restlessness, etc.) do not appear. 
Usually relief from the symptomatic condition is prompt and fairly complete 
in a few weeks. But it is only relief, and the effect must be kept up by smaller 
or less frequent doses of the thyroid for months or years, and perhaps through- 
out the life of the patient. Thyroid grafting and hypodermic injections of the 
liquid extract have been used. 



472 ACROMEGALY 

In addition, physiological methods should be employed to aid in maintain- 
ing a good nutrition, and especially in protecting the surface from cold. As a 
further aid any indicated constitutional remedy may be given. Cal. carb. has 
proved beneficial. 

ACROMEGALY 

{Marie's disease; Pachyacria.) 

Among the new formations of the connective tissues is placed this peculiar 
disease. Acromegaly or, better, pachyacria, is a rare disease characterized 
by progressive enlargement or thickening of the hands and feet. Some- 
times the prominent parts of the face and ears are also involved. The patho- 
logical changes consist in an actual thickening of the bones and cartilages 
with ho" elongation, and a hypertrophy of the skin and subcutaneous tissues. 
The skin is yellowish, sometimes pale and waxy; usually it is wrinkled and 
the growth of hair increased. 

Etiology. — The cause of the disease is unknown, although many believe 
it is due to tumors of the hypophysis. It appears principally in adult life and 
invariably advances through different stages of physical and mental decline 
to a fatal termination. "Whether the peculiar development of tissue is due to 
a diathesis beginning in middle or late life or to primary nerve disturbance 
is unsolved. It occurs in both sexes, but more often in males. 

The diagnosis is easily made on its characteristic features. The even 
enlargement of the hands and feet out of all normal proportion to other parts 
of the limb, giving "sausage shape" to the ringers and toes and general mas- 
siveness to all these parts, is not found alone in any other disease; while, 
about the face the exaggerated projections, such as the lower forehead, nose, 
lips, ears and chin, are equally characteristic. It may be confounded with 
myxcedema. The latter disease does not affect the bones, is attended with 
changes in the thyroid gland and the enlargement is due to deposits in the 
connective tissue. The symmetrical and uniform size of the whole body in 
what is known as "gigantism" is a sufficient difference on which to exclude 
acromegaly, while the limitation of the enlargements to the bones in rheu- 
matoid arthritis, beginning usually in the larger joints, one after another, 
and resulting in deformity, clearly distinguishes it from the disease in ques- 
tion. 

Treatment. — Because frequent anomalies of the thyroid and thymus 
glands have been noted in cases of acromegaly, thyroid extract and other 
animal extracts have been used internally, but with poor success. Treatment 
by indicated remedies may be formulated on any indications present, but 
there is little effect to be expected from any known drug. The lime salts 
deserve study for this disease, especially Cal. carb. 



CALLOSITAS 473 



B. BENIGN EPITHELIAL GROWTHS 

The new growths of epithelial origin, like those growing from connective 
tissue, are conveniently divided into a benign and a malignant variety. 

Of the benign growths, the simplest are those that consist of a mere thick- 
ening of the epidermis without marked enlargement of the underlying papilla?. 
These are the two common lesions, callositas and clavus, the less frequent 
growth, cornu cutaneum, and that peculiar thickening and cornification of 
the epithelia of the hair follicle known as keratosis follicularis. A second 
group may be made of those growths in which the thickening of the epidermis 
is associated with a marked hypertrophy of underlying papillae. These are 
verruca and papilloma cutis. A third group is formed by those benign growths 
which originate in the epithelia of the cutaneous glands. The glandular 
epithelia proliferate and build up small nodules and tumor masses, whose 
minute structure closely resembles that of the gland from which they spring. 
This latter class is represented by molluscum contagiosum, multiple benign 
cystic epithelioma and adenoma cutis. 



CALLOSITAS 

(Callosity; Callus; Tyloma; Tylosis.) 

Callositas or callosity is the name given to the hard and thickened 
patches of epidermis that form on parts exposed to intermittent friction 
or pressure. It is found most frequently on the palmar surface of the hand 
and the plantar surface of the foot. On the foot, callosity is caused by pro- 
longed walking or from the pressure of tight shoes; on the hand and fingers 
it is due to pressure or friction of some hard implement in frequent use. Hyde 
accentuates the fact that only intermittent pressure produces callosity; con- 
tinuous pressure results in atrophy or ulceration. 

The callosities are usually rounded, slightly elevated areas, very tough 
or horny in consistence and of a yellowish or brownish color. Microscopically, 
the callosity consists of a marked increase in number of the cells of stratum 
corneum, which are packed closely together, one layer upon another. There 
is no enlargement of the papilla? of the corium and the rete mucosum is thinned 
by pressure. The callosity is painless even when subjected to pressure. When 
the irritation which causes it ceases, the extra layers of epidermis usually 
scale off and the skin returns to its normal condition ; for callosity is merely 
protective to the part upon which it forms. At times callosities develop inde- 
pendently of pressure, in which case they are usually symmetrical ; such cases 
are supposed to be of neurotic origin and are now classed as keratoses. 

The treatment of callus when required is purely mechanical. The thick- 
ened corneous layer may be thinned with a file, rubbed down with pumice 



474 CLAVUS 

stone or pared down with a sharp knife; then salicylic acid plaster may be 
applied for a few days when the horny epithelium will be found loosened and 
can be peeled off. There can be no object in removing an ordinary callus 
unless the cause can be avoided. Ant. crud.) internally, may be of service in 
lessening an unusual tendency to callus. 



CLAVUS 

{Corn.) 

Clavus, or corn, resembles callosity in structure, being a simple thick- 
ening and hardening of the epidermis; it differs from callosity in forming 
a small rounded tumor instead of the diffuse thickening. In clavus, the 
epidermic cells of a circumscribed area multiply; those in the centre of the 
thickened area undergo a corneous metamorphosis, forming a central plug 
of horny substance, which is called the core or root of the corn. The central 
core extends inward to the corium, the papillae of which are usually congested 
and may be either hypertrophied or atrophied. Unlike callosity, clavus is often 
the seat of considerable pain caused by the pressure of the central core upon 
the sensitive papillae. The pain is often the result of external pressure, but 
there may be spontaneous pain which, like that of rheumatism or neuralgia, 
anticipates stormy weather with barometric accuracy. 

Clavus occurs almost exclusively upon the toes, especially upon the outer 
surface of the little toe. When occurring upon the outer surface, the corn is 
hard and dry and the surface has a horny gloss. It is then known as a hard 
corn. When occurring between the toes, the moisture of the skin macerates 
the thickened epidermis, forming a white, pulpy swelling which is called a 
soft corn. 

Etiology. — The cause of clavus, like that of callosity, is intermittent pres- 
sure. It is caused not only by tight shoes but by shoes that are not well fitted 
to the prominences of the foot. 

The treatment of corns has for its object the removal of the cause and 
then the removal of the hypertrophic horny tissue. Footwear, which, as 
Crocker says, "conform to the shape of the foot, instead of trying to make the 
foot conform to the boot," should take the place of ill-fitting shoes. For the 
relief of hard corns the centre may be cut out and the corns frequently rubbed 
with soap, then occasionally soaked in water, and as they become soft gradually 
pared down with a sharp knife; or, salicylic acid plaster or a ten per cent. 
resorcin plaster may be placed repeatedly over the corn and as the horny 
epithelia loosen they are peeled off with the plaster until the whole is re- 
moved. Afterwards, daily rubbing for a time with soap and alcohol will keep 
the part sound, provided the cause is removed. Hebra's Corn Eemedy may 
be used for either hard or soft corns, but it requires to be applied too frequently 
for the convenience of most people. It consists of 



CORN I CUTANE1 M 176 

R Salicylic acid Kr. 15. 

Ext. cannabis ind gr. S. 

Alcoholis m. 15. 

Etheris in. 10. 

Collodion flexile m. 75. M. 

This solution is painted over the corn with a brush three times a day for 
a week, then, after soaking the part in hot water, the corn can be picked out. 
While soft corns are being treated, thin soft felt or wool may be worn between 
the toes during the day. Temporary relief from a painful corn may be obtained 
by wearing a corn plaster with an open centre, which allows its being lilted 
around and shifts the pressure from the growth. This opening also permits 
of applications to the corn while the plaster is in place. Corns should not be 
treated so as to excite inflammation. The author has seen one case of gan- 
grene of the toe, necessitating amputation of the toe and a part of the meta- 
tarsal bone following from harsh domestic treatment. If corns are sensitive 
or persist after the mechanical causes are removed indicated drugs such as 
Ant. crud., Cal. carb., Xat. mur. and Sulphur may be useful. 



CORNU CUTANEUM 

(Comu humanum; Cutaneous horn.) 

Cornu cutaneum, cutaneous horn or horny excrescences may occur on any 
portion of the body, but are most frequently found on the scalp, face and penis. 
They are usually single, but may be multiple. The horn is generally quite 
small and resembles in its curved shape and hard substance the horns of the 
lower animals. The substance of the horn consists of epithelium, or of a 
mixture of sebaceous matter and epithelium which has undergone corneous 
transformation. As found in the horn, the epithelia are thin scales arranged 
in concentric layers around several small central spaces; like the cells of the 
stratum corneum, they have no nuclei. The growth seems to originate prin- 
cipally from the cells of the rete mucosum, though it sometimes springs from 
the epithelia of the sebaceous glands. Beneath the horn there is usually some 
slight enlargement of the papilla? of the corium. 

The cutaneous horn is tough, hard and dry. Its surface is wrinkled trans- 
versely and striated longitudinally. Its color is yellow, brown or black. After 
a horn has grown to a certain size it is apt to drop off, leaving an eroded sur- 
face from which a new horn is likely to grow. At times a horn will attain a 
remarkable length, some cases being recorded in which it measured fifteen to 
twenty centimetres. 

Sutton classifies cutaneous horns as wart horns, sebaceous horns, cicatricia 
horns and nail horns. The wart horn grows from an ordinary wart. The 
sebaceous horn develops from a ruptured sebaceous cyst, and can only he 
distinguished from the wart horn by the presence of such a cyst at its base. 



476 KERATOSIS FOLLICULARIS 

The cicatricial horns are uncommon; they develop from a scar, especially 
the scar of a burn. The nail horn grows from the distorted toe nails of bed- 
ridden patients, most commonly from the great toe. 

According to Lebert, of the recorded case's of cutaneous horns twelve per 
cent, have been the starting point of an epithelioma; this occurs particularly 
with wart horns. Aside from this fact, cutaneous horns have no bearing on 
the general health. 

Etiology. — Of the causes of cutaneous horns we know nothing aside from 
their secondary origin as classed by Sutton, and their almost exclusive occur- 
rence after middle life. They have been observed, however, at all ages and 
a very few in infancy. One of my own cases in a girl of seven was said to 
have existed from birth. 

Treatment. — In view of the liability of epithelioma to develop at the 
site of horns they should be completely removed. This may be done by first 
softening them with hot alkaline water dressings and then cutting or paring 
them down to the base; then the latter may be destroyed by chloride of zinc 
paste, or curetted and dressed antiseptically. If the base is cystic it may need 
to be dissected out, and sometimes it is better to give an anaesthetic and remove 
the growth by excision, leaving a closed wound and hence a smaller scar. 
Horns may be cut down and made less conspicuous or troublesome, but unless 
the base is destroyed they will continue to grow. 



KERATOSIS FOLLICULARIS 

(Ichthyosis follicularis ; Ichthyosis sebacea cornea; Psorospermose folliculaire 
vegetante; Darter's disease.) 

Keratosis follicularis is a rare disease which consists in the appearance of 
minute papules on the scalp, face, groins, hypogastrium and over the sternum. 
The peculiarity of the papule is that it contains a dark colored horny plug, 
which is imbedded in a hair follicle and projects above the surrounding 
skin surface. The plug is readily picked out, leaving the dilated follicle 
as a small pit. Surrounding the horny plug there may be dark colored greasy 
scales resembling those of seborrhceic eczema. In the folds of the skin where 
there is much moisture, as in the groins, around the anus and behind the ears, 
the papules may enlarge, become eroded and discharge an abundant sero- 
purulent secretion. Microscopically, the disease consists in an active prolifera- 
tion of the epithelia that line the ducts of a sebaceous gland and the adjoining 
hair follicles. Both duct and follicles are dilated by a mass of cells that have 
undergone corneous change and constitute the peculiar plugs that are char- 
acteristic of the disease. This rapid formation of epithelia, and the corneous 
transformation, while perfectly normal in the adjoining epidermis, are decid- 
edly abnormal when occurring in a hair follicle and the duct of a sebaceous 
gland. 



VERRUCA J77 

Etiology. — The cause of the misplaced cornificatioo is as yet undemoa- 
strated. Of twenty cases of keratosis follicularis that have been coll' 
thirteen occurred in males and a majority began before the age of twenty-five 
years. Several of the cases have occurred in the same family, a fact that points 
with equal force to heredity and to contagion. Darier. who has studied the 
disease closely, at first claimed that many of the epithelia of the duct contain 
bodies that he regarded as psorosperms. He believed the disease to be due 
to these parasites, a follicular psorospermosis analogous to Paget's disease of 
the nipple and molluscum contagiosum. This view of Darier was corroborated 
by Wickham. As the result of new investigations, the propounders of the 
above theory as well as other authorities agree that the bodies which resemble 
psorosperms are produced by cell-transformation. 

The prognosis of this curious disease is unfavorable as to cure. The 
disease attacks progressively fresh areas of skin, and the older lesions remain 
unchanged or increase in size. There is seldom any associated affection of 
the general health, though if there is ulceration of the inguinal or other 
lesions the resulting distress and disturbance of sleep may wear decidedly 
upon the constitutional powers. 

The diagnosis is made upon the presence of the papules with their peculiar 
plugs, and the tendency to ulceration in the groins or behind the ears. The 
disease can hardly be mistaken for keratosis pilaris or for seborrheic eczema, 
to which articles the reader is referred for their differential points. 

Treatment. — As this has been unsatisfactory so far, the field is an open 
one. The local methods employed for ichthyosis have been suggested, and 
Crocker says he should be inclined to try soft soap inunctions, followed by 
sulphide of potassium baths for an hour daily, or baths at some sulphur spring. 
It would seem as though alkaline or saline baths with frictions, followed, or 
perhaps preceded by, rubbing with a weak salicylic acid ointment, ought to 
prove beneficial, as it does in simpler forms of keratosis. 

Internally some remedy known to have an affinity or predilection for 
epithelial structures of the hair follicle may be* selected on this and any symp- 
toms found in a given case. 



VERRUCA 

(Wart.) 

The name verruca or wart has been applied to several forms of excrescence 
upon the skin. The most frequent variety is the verruca vulgaris, or common 
wart, which is usually a small elevation, the surface of which is roughened and 
horny. It may be scarcely elevated above the surrounding skin or it may 
attain a height of one-eighth of an inch; its color is pink, yellow or gray. 
Common warts are usually found in children, especially upon the hands and 
face. They often disappear spontaneously (verruca caducea) ; on the other 



478 VERRUCA 

hand, they may be very persistent, recurring several times after removal 
(verruca perstans). Warts are usually due to some external irritant applied 
to the skin, probably parasitic in nature and often auto-inoculable. Some 
warts are undoubtedly contagious, while others are congenital. The different 
clinical forms of wart have been designated by various names. 

Verruca filiformis is a slender sessile growth, often isolated, sometimes 
multiple and grouped, and quite often seen upon the neck or shoulders of 
adults ; rarely they are congenital. Verruca plana refers to flat warts, from a 
pin-head to a half inch in diameter. Verruca digitata is applied to finger- 
like warts, made up of several distinct lobules or parts. A peculiar variety 
of verruca vulgaris is seen in adults, especially in laborers, as a dense warty 
growth along the margin of the finger nails. 

Verruca senilis (seborrheic wart, keratosis pigmentosa) is that variety of 
wart that appears upon the neck, shoulders and arms of old people, in con- 
junction with other senile changes of the skin. They are usually multiple, 
often pigmented and may attain a large size. 

Verruca necrogenica (anatomical tubercle, post-mortem wart) is an un- 
doubtedly contagious form of warty growth, occurring usually on the hands as 
a result of inoculation from a corpse. In most instances it is a form of tuber- 
culosis of the skin (q. v.). 

Verruca acuminata (condyloma acuminata; venereal wart; fig wart) has 
little resemblance to the other forms of verruca. It is found about the genitals 
and anus, sometimes upon the face, as a fleshy elevation that tapers to a point. 
Pointed condylomata are usually found in groups and may attain a very large 
size. They are pink or red in color and often excrete an offensive, purulent 
liquid, and bleed easily. When upon the face, or when not associated with 
friction, heat or moisture, the surface may become hard and roughened, like 
an ordinary wart. 

Etiology. — The causes are unknown, although there can be no doubt that 
the great majority of warts are nests of various types of micro-organisms. In 
childhood especially it is a fact that they may result from external contact, and 
probably they are feebly auto-inoculable and infectious. Jadassohn has de- 
veloped warty lesions in the human species by inserting fragments of warts 
in superficial incisions of the epidermis. Senile warts are probably due to 
changes in the nutrition of the skin, incident to old age. The cause of the 
pointed condyloma or venereal wart is a local irritant, as the discharge of 
gonorrhoea, leucorrhcea or a chancroidal ulcer. The irritant need not neces- 
sarily be venereal, as shown by numerous instances. The condyloma acuminata 
has no connection with syphilis nor with the broad, flat, syphilitic condyloma, 
for the latter is a growth from a syphilitic papvde or mucous patch. 

Pathology. — In the formation of all verruca, the essential pathological 
change is a thickening of the prickle-cell layers of the epidermis, from which 
fact Auspitz well named these growths acanthomata (Gr. acantha. a thorn or 
prickle). The elevation consists principally of thickened epidermis which also 
burrows down between the papilla? of the corium. flattening them laterally into 
long, slender, branching arms of fibrous tissue. 



VERRUCA 478 

Prognosis. — In themselves, verrucas arc innocenl growths. It should be 
remembered, however, that epithelioma sometimes develops from an apparently 
innocent wart, or, rather, that the early stage of some epitheliomata closely 
resembles a simple wart. Theoretically, the verruca necrogenica may be fol- 
lowed by general tubercular infection; but, practically, the growth, while apt 
to recur after removal, remains as a local disease of the skin, slowly extend- 
ing over a variable area. 

Treatment. — Ordinary warts have been cured so many times by sugges- 
tion that this may constitute a part of any non-operative treatment. Definite 
directions as to the hour and minute of taking a dose or making a local applica- 
tion may accomplish this, but should not be repeated many times in succession. 
In the case of warts it seems almost as essential to forget their existence as to 
first fix the mind upon them. They disappear, but no one has ever witnessed 
their sudden recession or seen them fall. Whatever remedy is found indicated 
internally may be applied to the wart at the same time the dose is taken, re- 
peated two or three times a day at an exact hour for a few days, and then 
omitted for a week or longer. This short course may be renewed as many 
times as needed and is frequently effective. 

Sulphate of magnesia, nitromuriatic acid and arsenic in full doses have 
been recommended for the cure of warts. They do not appear to have any 
advantage over individualized remedies given in small doses. 

If local methods are relied on. they may vary with the kind, number and 
location of the growths. Ordinary warts may be covered with salicylic acid 
plaster or painted with salicylic acid collodion until the horny layer is re- 
moved and then touched with dilute acetic acid twice a day ; or, glacial acetic 
acid, or the ethylate of sodium may be applied and repeated after each crust 
separates until the whole is reduced. Nitric or chromic acid serve the same 
purpose, but they are more painful. For more extensive warts a saturated 
solution of salicylic acid in alcohol frequently applied is often serviceable. If 
this fails, painting occasionally with tincture of iodine, or a twenty per cent, 
solution of resorcin. may be tried before resorting to the use of caustics as 
mentioned for single or smaller warts. A saturated solution of potassium 
bichromate made with boiling water but applied cold once daily may be useful. 
The high frequency currents (Oudin resonator) have been successfully used. 
Warts have been removed by a few exposures from a soft X-ray tube, but radio- 
therapy has not given as uniform favorable results in the treatment of these 
conditions as one might expect. Radium and concentrated solar rays have also 
been used. 

Filiform and digitate growths may be cut off with curved scissors, the 
base touched with the pointed stick of nitrate of silver, with carbolic acid or 
powdered tannin. Pedunculated warts may be treated in the same way, or if 
large, as they are apt to bleed freely, they may be removed by the gal va no- 
cautery. Acuminate or moist warts may be made to disappear by keeping them 
perfectly clean, dry and dusted with a finely powdered boric acid or salicylic 
acid and starch, and, if needed, occasionally brushing them over with a solu- 
tion of persulphate of iron. 



480 PAPILLOMA CUTIS 

When a patient solicits the quick removal of one or a small number of com- 
mon warts they can be removed with the dermal curette, followed by cauteriz- 
ing the base ; or when of large size, by excision as for other growths of similar 
size. Electrolysis may be employed for the removal of warts, especially when 
they tend to return, and the galvanic ecraseur when unusually vascular. The 
verrucae which sometimes appear during pregnancy should not be interfered 
with. After pregnancy if they do not disappear, as they are likely to in a 
reasonable time, they may be treated according to their kind and location. 

The seborrhceic warts occurring almost exclusively in old age are included 
under verruca senilis, and if treated at all may be dressed occasionally with a 
five to ten per cent, plaster of resorcin, naphthol or salicylic acid. If operative 
measures are demanded the Paquelin cautery has been recommended. 

Among drugs which may be indicated for combined internal and external 
use see indications for Ant. crud., Baryta carb., B. iod., Gal. carb., Carbo 
animal., Caust., Kali mur., Lycop., Nat. mur., Nat. sulph., Phos., P. acid, 
Psor., Sepia, Sul., Thuja. 



PAPILLOMA CUTIS 

The word papilloma is of little further service in dermatological nomencla- 
ture, though still used to a large extent in clinical surgery. The work of 
Auspitz, Virchow and TJnna having separated the warts or verrucae from the 
papillomata there remains no specific growth to which the name can be applied, 
and the word has come to rank with " tubercle " or " papule " as the name of 
a lesion of a disease rather than the disease itself. Thus, cutaneous growths 
that are " larger than a tubercle and smaller than a tumor," having a rough- 
ened or warty surface, are called papillomata. Such growths occur in mycosis 
fungoides and in dermatitis medicamentosa, particularly in the iodine and 
bromine eruptions. 

Neuropathic papilloma or naevus unius lateris consists of a row or rows of 
warty growths that appear along the course of a nerve trunk or its branches. 
They are supposed to be associated with some nerve lesion. Von Eeckling- 
hausen suggests that they are the result of a congenital neuritis. 

Diagnosis. — Papillomatous growths may be recognized by their size, their 
outer covering of either vegetating or dry and horny epithelium, and by the 
absence of the characteristic signs of other neoplasms. 

The treatment is that of the disease or condition from which they origi- 
nated. The bromine and iodine salts are worthy of study. For the so-called 
neuropathic form see drugs suggested for verruca?. 







Fig. 127.— NEUROPATHIC PAPILLOMA 

N-ffiVUS UNITJS LATKHIS 

Subject is a young vigorous boy with a history of a gradual development of the 
warty growths. No effect was observed from temporary treatment. 



MOLLUSC UM CONTAQI08UM »-I 



MOLLUSCUM CONTAGIOSUM 

(Molluscum sebaceum; M. epitheliale; M. verrucosum; M. sessile; Epithelioma 
contagiosum; Acne varioliformis.) 

Molluscum contagiosum or epithelioma contagiosum is characterized by the 
appearance of small, pink, pearly or yellowish nodules, usually occurring upon 
the face and also, in adults, upon the genitals. The nodule begins as a papule 
that grows, in several weeks, to the size of a small pea. The developed nodule 
is globular in shape, firm and elastic to the touch and presents at its sum- 
mit a small opening from which a waxy or colloid substance may be 
squeezed out. Atmospheric dust adhering to the tip of the waxy plug forms 
a small black spot, as in comedo. "With exceptional variety the growths may 
increase to the size of an orange (molluscum giganteum). 

The disease is always benign and unattended by constitutional symptoms. 
Having attained their full size, the little tumors remain stationary for some 
months. Within a year they usually undergo absorption and disappear spon- 
taneously. No scar or disfigurement remains unless, indeed, caused by the 
harsh treatment to which these innocent growths are sometimes subjected. 

Etiology and Pathology. — As the name implies, molluscum contagiosum 
is a contagious disease. Well authenticated cases are recorded of its transmis- 
sion from one child to another or from an infant's face to the maternal breast 
and vice versa. Sometimes, as with ringworm and impetigo contagiosa, an 
epidemic of the disease will run through a school or family. The nature of 
the contagion is still a matter of dispute. It is probably a parasitic disease, 
but the parasite remains undemonstrated. Unhygienic conditions are predis- 
posing causes. 

The globular nodule of molluscum contagiosum consists of the central 
waxy plug surrounded by clumps of epithelia that suggest the lobulated struc- 
ture of the sebaceous glands. The waxy substance consists of degenerated 
epithelia and fat globules. In this debris are found a number of oval, epithe- 
lium-like bodies, that have a glistening appearance and do not stain in the 
same manner as the surrounding epithelia. They are the so-called " mol- 
luscum bodies " that were formerly regarded as parasites (psorosperms) and 
the cause of the disease. Most pathologists now regard them as mere de- 
generated epithelia. Another debatable point is the origin of the epithelia 
that constitute the molluscum. The sebaceous glands, the hair follicles and 
the surface epithelium have all been described as the starting points of the 
growth ; at present the theory of origin from the surface epithelium is accepted. 
A proliferation of the epithelial cells in the lower layers of the rete is the 
first part of the process and the growth is confined to the rete. 

Diagnosis. — The common location on the face, neck or genitals, pea-size, 
waxy appearance, and central opening from which a soft substance can be 
expressed will distinguish the lesions of molluscum contagiosum from all 



482 MULTIPLE BENIGN CYSTIC EPITHELIOMA 

other eruptions. When small they might be mistaken for milium, but the 
presence of a central opening or umbilication, which is never found in milium, 
will serve to exclude the latter. All vesicular' eruptions may be excluded by 
picking the growth and ascertaining that it does not contain serum. 

Treatment. — While treatment should be prompt on account of the prob- 
able elements of contagion in the lesion, it is to be kept in mind that these 
growths usually disappear spontaneously in time without leaving scars ; there- 
fore, no radical method should be instituted which is at all likely to result in 
scar formation. An effectual procedure is to incise the growths just enough 
to permit of their contents being easily expressed. Neither the incision nor 
pressure gives much pain, and after the bleeding stops the only after treatment 
needed is an occasional dusting with some antiseptic powder, such as boric acid, 
or salicylic acid one to ten parts of talc. When the lesions are small they may be 
touched with carbolic acid on a pointed toothpick; or, if numerous as well as 
smalh>they may be rubbed vigorously twice a day with green soap, or a five 
per cent, resorcin or salicylic acid ointment. Kali iod. is indicated in some 
cases. 

The prognosis for cure is always favorable, but cases vary in their duration. 



MULTIPLE BENIGN CYSTIC EPITHELIOMA 

(Epithelioma adenoides cysticum; Adenoma of the sweat glands, etc.) 

In this rare disease are combined the minute structure of an epithelioma 
with the clinical history of a benign growth. As implied in the name, the 
tumors are multiple. They are found scattered more or less thickly over the 
face, chest and back. The tumors appear in the form of nodules varying 
from the size of a millet seed to that of a large pea. The color is that of 
the surrounding skin, or the nodules may be yellowish and present the 
distended and shining appearance of a vesicle. On microscopic examination 
the tumors are found to consist of fibrous tissue containing solid masses of 
epithelial cells, some of which are arranged in the whirls that are so frequently 
found in squamous-celled epithelioma. In multiple benign cystic epithelioma 
many of the epithelia undergo colloid degeneration; it is these masses of trans- 
lucent colloid substance that give the tumor the appearance of a vesicle dis- 
tended with serum. The connective tissue in which the epithelia are im- 
bedded does not present the intense infiltration of round cells that is usually 
found in malignant epithelioma. Differentiation between the malignant and 
the benign form, however, cannot be made by microscopic examination, so 
closely do they resemble each other. 

The origin of the epithelial new growth has not been determined. For- 
dyce seems to have traced it to the epithelia of the hair follicles, while Darier 
had previously declared that the new epithelia sprang from the sweat glands. 
Unlike the true epithelioma, multiple benign cystic epithelioma never ulcerates. 



ADENOMA 188 

It causes no pain or other subjective symptom, there is no enlargement of the 
neighboring lymph glands nor development of cachexia. The growth Beema 
to have no effect upon the general health. Its cause is unknown. In i\\" 
instances the occurrence of several cases in the same family has been reported. 
They may be treated by incision and expressing of their contents, or by 
removal with the dermal curette. A small, slightly depressed scar is left after 
healing of the wound. Electrolysis may be of service for the smaller growths. 



ADENOMA 

{Vegetation vasculairej Nosvi vasculaires et paplUaires; Adenoma sebaceum; 

Adenoma of the sebaceous glands.) 

Adenoma is a neoplasm consisting of newly formed gland tubules and 
acini, together with the requisite supporting connective tissue and blood- 
vessels. When occurring in the skin adenomata grow almost exclusively 
from the sebaceous glands; the sweat glands seem to enjoy nearly complete 
exemption from the development of new growths, either malignant or benign. 
Several cases of true neoplasms have been recorded which appeared to the 
observer to arise from sweat glands, but the proofs of such origin are not con- 
clusive. That rare disease that was formerly known as hydradenoma, or 
adenoma of the sweat glands, is now regarded as originating in the epithelia 
of the hair follicles, and is here classed and described as multiple benign cystic 
epithelioma. Practically, all adenomata of the skin are included in the name 
adenoma sebaceum. 

If we exclude sebaceous cysts or wens from the category of adenomata, 
adenoma sebaceum becomes an infrequent disease. Xearly all the recorded 
cases have been observed in dispensary practice, that is, among the poor, and 
Crocker believes " the disease is of congenital origin, and all the marked cases 
show intellectual inferiority." The tumors are multiple and occur upon the 
face, especially upon the side of the nose and in the naso-labial fold. They 
occur as small papules which are often of a bright red color from the numerous 
distended capillaries they contain: for this reason they were given the name 
vegetations vasculaires by Eayer, and noevi vasculaires et papillaires by Vidal. 
In other cases the color is that of the normal skin. The substance of the 
papules undergoes cystic degeneration, forming a minute point of sebum-like 
substance. 

Diagnosis. — There may be a resemblance to multiple benign cystic epithe- 
lioma, rosacea and colloid degeneration of the skin. Adenoma sebaceum may 
be distinguished from multiple benign cystic epithelioma by the distribution 
of the eruption; the benign epithelioma occurring on the arms, hack and (.lust 
as well as upon the face, while in the adenoma the papules are confined to the 
face and are apt to be grouped at the side of the nose. To make an exact 
diagnosis, microscopic examination is required. From rosacea papules by the 



484 LEUCOKERATOSIS BUCCALIS 

early history slow evolution and stationary behavior of adenoma and an 
absence of tendency to suppuration. From colloid milium by the tendency 
of adenoma to be situated about the nose and lower face, its more numerous 
and reddish lesions with associated telangiectasis. While the colloid growths 
usually occupy the frontal and orbital regions, are rarely numerous, have a 
yellowish translucent look and an absence of dilated capillaries. 

Prognosis. — Permanency is a feature of these growths. Earely partial 
involution has been noted in some lesions, but more often the number has 
increased, and after removal they tend to return. 

Treatment. — Failure rather than success has attended local measures 
of treatment thus far. Crocker has effected a cure in one case where the 
lesions were small by electrolysis, and greatly improved another where the 
lesions were larger by excision. Pollitzer has cured one case by repeated mul- 
tiple scarifications, and the author has cured one by curetting, followed by 
repeated cauterizing with carbolic acid. Thuja first decimal was given to the 
patient internally before the employment of the curette, and it is quite possible 
that an indicated tissue remedy like Fluor, aoid bearing some relation to the 
probable origin and pathological character of the disease might aid in its cure 
when administered internally. 



LEUCOKERATOSIS BUCCALIS 

(Leucoplahia; Ichthyosis Ungues; Psoriasis linguse; Smokers' patches of the 

mouth, etc.) 

The above title was given by Besnier and Donyon to conditions of the 
mucous membrane first described by Bazin in 1868. It nearly always occurs 
in the mouth of men and commonly after middle life, but has been observed in 
the female in the mouth and on the vulva. The chief sites of the disease in 
the mouth are the inner surface of the cheeks on a line with the junction of the 
teeth when pressed together; the gums adjacent to the lateral incisor and 
canine teeth; the mucous fold alongside the floor and roof of the mouth and 
gums; the edges and dorsal surface of the tongue. 

The lesions consist of variously shaped glistening, bluish to ivory white 
patches, which feel more or less rough to touch with the finger or to contact 
with the patient's tongue and are sometimes warty or fissured. They may 
excite salivation, lessen the mobility or give a sense of stiffness to the part, 
but are seldom painful unless they become dense enough to form deep cracks 
and excite some degree of inflammation. The latter condition may give rise 
to soreness and pain, lead to ulceration and sometimes to cancer of the part. 

The course of leucoplakia of the mouth is usually very slow, often taking 
years for its full development and commonly proving very resistant to treat- 
ment, though rarely the lesions may undergo resolution without local appli- 
cations. They may or may not recur after complete removal. 



LEUCOKERATOSIS BUCCALIS 186 

Etiology. — Probably most cases originate from repeated irritation or 
from previous disease; occasionally no assignable cause can be round. Most 
subjects of this disease smoke or chew tobacco and it is believed to this habit 
its origin is frequently due. Irritation from broken or decayed teeth is a 
local factor in some cases, while syphilis, lithaemia, psoriasis, gaatro-intestinal 
disorders and neurotic disturbances are conditions to which the disease lias 
been attributed. 

Pathology. — The pathological changes consist of hyperkeratinization of 
the more superficial epithelium and inflammation of the papillary layer of the 
corium, but which is primary is unknown. The cells of the horny layer which 
is hypertrophied retain their nuclei; while in the derma is found infiltration 
and partial obliteration of the papilla?. 

Diagnosis. — Lichen planus of the mouth may closely resemble this disease, 
but lesions of the former usually occur in disk, linear, festoon or ring shapes 
of a silver whitish color and not always occupying the points of election of the 
latter. Moreover, characteristic lichen papules or their effects may be usually 
found on the skin. Syphilitic patches of the mucous membrane may be dis- 
tinguished from leucokeratosis by their softness, quicker development, tend- 
ency to ulcerate. A history of syphilitic infection and subsequent eruptions 
on the skin, etc., may also aid diagnosis. 

Prognosis. — The great majority of cases prove amenable to treatment 
because they follow the necessary advice. For all others, an epithclioniatous 
development is possible. 

Treatment. — Causal methods are usually essential to cure. Total ab- 
stinence from tobacco or irritating articles in food or drink should be strictly 
adhered to by the patient. The teeth should receive every necessary attention 
if found to stand in causal relation to the lesions. Any existing departure 
from health should be corrected by physiological living and other remedial 
treatment adapted to the general or special needs of each case. 

Locally, excision, nitrate of silver and other caustics, the galvano-cauiery. 
erasion with the dermal curette or with the denial burr and engine, applica- 
tion of lactic acid, one per cent, of chromic acid, one-half per cent, solution of 
corrosive sublimate, two to five per cent, of bichromate of potash, five to thirty 
per cent, of salicylic acid, etc., have been employed with some degree of suc- 
cess in different cases. The author has seen the best effects from mild applica- 
tions calculated to soften the hardened epithelium and lessen inflammation. 
A twelve per cent, boroglyceride containing half of one per cent, of menthol 
applied once or twice daily is a serviceable preparation. The curette 1ms been 
used occasionally to scrape away loosened corneous epithelium. In one case 
which did not respond to the foregoing, carbolic acid was applied several times 
at weekly intervals for its mild caustic and stimulating effect with <rood result. 
Hyde reports good results in two cases from radiotherapy. 

Apis, second decimal, and Rhus tox., in the same attenuation, have been 
verified as remedies. An indicated di-ug should always be prescribed. 



486 CANCER— EPITHELIOMA 

C. MALIGNANT EPITHELIAL GROWTHS 

CANCER 

The term cancer includes all those neoplasms that are caused by the inva- 
sion of the lymph spaces of a tissue by growing epithelial cells. All forms of 
cancer are malignant ; that is, they often recur after removal, invade the sur- 
rounding tissues, are reproduced in other parts of the body and tend to de- 
stroy life. 

Cancers of the skin are divided into epithelioma, rodent ulcer, Paget's 
disease of the nipple and carcinoma cutis. Eodent ulcer and Pagetfs disease 
are now regarded as peculiar varieties of epithelioma. Carcinoma cutis might 
welLhe considered under malignant connective tissue growths, because it prin- 
cipally involves the connective tissue, secondary to its primary appearing in 
some deeper structure, but because of its pathological relation to other cancers, 
it is considered with the malignant epithelial growths. 

In dermatology the name epithelioma (epithelial tumor) is still reserved 
for those neoplasms that arise from the epithelia of the skin or mucous mem- 
brane as distinguished from those forms of cancer that originate beneath the 
skin and attack the skin secondarily, as cancers of the breast or parotid gland. 

EPITHELIOMA 

{Cancroid; Epithelial carcinoma; Epithelial cancer; Skin cancer.) 

Epithelioma or cancroid ulcer is the variety of cancer that comes most 
frequently under the observation of the dermatologist. Helmuth states that, 
in his experience, it is the most frequent of all cancers. It may occur upon 
any part of the body, but develops with greatest frequency upon the lower 
lip, tongue, face, penis, os uteri and female genitalia. 

Epithelioma begins as a small papule or warty elevation which may re- 
main stationary for a number of years. The surface of the papule may be 
smooth or fissured, and it may be covered with a thin crust that persistently 
reappears after removal. After a longer or shorter time the papule ulcerates 
at the centre. As the ulcer enlarges, elevation and induration of the skin 
precede it so that the margin of the ulcer is always elevated and hard, and 
often nodular. The hardness and elevation are very characteristic of epithe- 
lioma, and are due to the distension of the lymph space of the corium with 
growing epithelia. In its early stage the ulcer is often covered by a dark 
crust, consisting of dried blood and serum. Later on, the discharge is quite 
profuse and the ulcer bleeds with the slightest irritation. When ulceration 
begins the pain is frequently intense; it is usually burning and often worse 
at night. Intense lancinating pains may be also present and quite character- 
istic of this growth. 




Fig. 128.— EPITHELIOMA 

BEFORE TREATMENT 




Fig. 129.— EPITHELIOMA 

AFTER TREATMENT ACUTE, MALIGNANT TYPE 

Patient, girl of eighteen, with a tubercular family history. At the age of 
puberty she had eczema with enlarged glands in the affected areas. Later she ex- 
perienced sharp, lancinating pains about the lower lip and extending into the sub- 
lingual and sub-maxillary glands. A month later the glands were larger, and what 
seemed to be a blister appeared on the lower lip. In three months the growth pre- 
sented the appearance shown in upper cut, when a diagnosis of epithelioma was 
made and confirmed by microscope. The crust was removed and a sixty per cent. 
arsenic paste applied; the slough therefrom w r as removed twenty-six hours later. 
Symptoms of arsenic poisoning, viz.: burning, restlessness, oedema beneath the eyes, 
suppression of urine and much greater swelling of the glands followed. Arsenicum , 
thirtieth, was prescribed for three months, with the result depicted in the second 
illustration, and a cure of all symptoms. (Courtesy of Dr. George Royal.) 




Fig. 130.— EPITHELIOMA 



Patient is a man of about sixty years. Duration of disease, three years. Lo- 
cated on the right leg. The illustration represents about the exact size and shows 
the nodular character of the patch. Microscopic examination verified the clinical 
diagnosis of epithelioma. 



RODENT ULCEB 1-7 

These epitheliomata that spread on the surface and do not borrow deeply 
into the tissues are classed, clinically, as superficial or discoid epitheliomata. 
The initial papule ma}' be quiescent for ten or twenty years before ulcerating; 
the ulcer enlarges slowly and the lymph glands remain long unaffected. I 
epitheliomata that grow rapidly, ulcerate early and eat deeply into tbe sur- 
rounding tissues are called deep-seated or nodular epitheliomata from the fact 
that the initial lesion is frequently a nodule buried in the skin of the mucous 
membrane rather than a papule. Nodular epitheliomata may form early 
metastasis in the lymph-nodes and internal organs, the patient pass into the 
weak, anaemic and emaciated state known as the cancerous cachexia, and 
death soon follow. 

Occasionally the superficial form is characterized by papillary growths on 
the surface, which may also give it a granulated appearance, or the outgrowths 
may assume warty, cauliflowerlike or even pedunculated shapes. Such cases 
have been called papillary epithelioma. Later in its course when ulceration 
occurs it resembles the nodular form. Chimney sweepers and workers in 
paraffin and tar sometimes develop on the scrotum or other parts of the skin 
a dermatitis which may ultimately become the seat of epithelioma. These 
have been termed chimney sweep's cancer, paraffin cancer, etc. 



RODENT ULCER 

(Jacob's ulcer; Cancroid ulcer; Ulcus exedens; Noli-me-tangere.) 

Rodent ulcer or Jacob's ulcer is a form of epithelioma characterized by 
almost absolute limitation to the upper part of the face, slow course, pain- 
lessness, slight new growth in proportion to the ulceration, and the ab- 
sence of metastasis or cachexia. 

It is found most frequently on the eyelid and near the eyes. It commences 
as a small, soft, brownish or reddish nodule, about one millimetre high, that 
spreads slowly outward. A thin crust often forms over the growth. After 
a time the crust falls off, leaving a smooth, red, superficial ulcer. In the end 
the ulcer destroys the eye and even the bones of face and skull, but it lacks 
the elevated, indurated and nodular border, the free discharge, the fungous 
growths, the metastasis and cachexia that would be present in a typical 
epithelioma of equal extent. 

While rodent ulcer is undoubtedly an epithelial new growth, observers 
differ as to the origin of the new cells. Unna derives them from the rete 
Malpighi, Thiersch from the sebaceous glands and Thin from the sweat glands, 
while Darier states that they may come from any or all of these structur.es. 






488 PAGET'S DISEASE OF THE NIPPLE 



PAGET'S DISEASE OF THE NIPPLE 

(Malignant papillary dermatitis; MamMlaris maligna; Eczematous epithe- 
Homatosis of the nipple, etc.) 

This is a variety of epithelioma first described by Paget in 1874. It occurs 
almost exclusively in women and usually attacks the areola of the right 
breast. In the early stage a well defined, intensely red, granular looking 
patch forms on the surface, from which exudes an abundant viscid secretion. 
Occasionally the affected surface may be covered with scales or crusts, and 
burning or itching sensations give a subjective as well as an objective resem- 
blance to eczema. Prom a small round lesion half an inch or less in diameter, 
extension may occur uniformly or less regularly until all of the areola and 
some of the outlying skin is invaded. After a variable duration running into 
months or years, a buttonlike infiltration occurs into the whole thickness of 
the skin beneath the surface lesion and which can be appreciated by pinching 
up the patch with the thumb and fingers. Following the induration, perhaps 
years later, the nipple becomes more and more retracted, and if the process 
is not arrested by treatment nodular growths in the skin or deeper parts may 
develop, ulceration and the usual train of symptoms of cancer of the whole 
breast ensue. 

The duration of the disease varies widely from four to twenty or more 
years. One case in a woman of seventy, under the author's observation during 
the last year of life, when the whole breast was involved, gave a history of 
beginning with a typical lesion three years before; a duration of four years 
ending in death from cachexia. In another case induration was apparent at 
the end of two years, but was arrested by treatment without further develop- 
ment. 

Although Paget's disease in its evolution becomes an epithelioma, authori- 
ties differ in opinion as to its primary nature, some believing it begins as a 
keratosis, others as an eczematous type of inflammation, while later investi- 
gators are inclined to view it as epitheliomatous from the start. Cases of the 
disease on the penis and scrotum, and one ease on the nipple of a man, have 
been reported. Hyde states that in such cases the process is identical with that 
of superficial discoid epithelioma. 

Etiology of Epitheliomata. — The efficient cause of epithelioma is un- 
known. The disease has been observed to follow prolonged irritation, inflam- 
mation or degeneration of the skin or mucous membrane. Thus a sharp or 
uneven tooth may so irritate the tongue as to finally excite an abnormal growth 
of epithelium characteristic of this disease. In a like manner the disease may 
follow from the habitual pressure of a pipe stem on the lip or tongue; the 
repeated excoriation of warts, nam and other benign growths, or from scratch- 



PATHOLOGY AND DIAGNOSIS OF Kl'l I 1 1 1 I.IOMATA 189 

ing to relieve chronic pruritus. The prolonged inflammation in a leeioi 
psoriasis or from an ulcer, and long or repeated contact of irritating sub- 
stances with the skin, such as soot, tar, paraffin, etc., may be the apparent 
cause. Men are more subject to epithelioma of the lip than women, due to 
the difference of the sexes in the one habit of smoking. More than ninety per 
cent, of all cases of cancer of the lip have occurred in smokers of tobacco, 
while the very few women who have suffered from cancer of the lip have been 
smokers. Heredity is believed by Lewis to be a minor influence, and the disease 
is rare under thirty, though occasionally a malignant type of cancer is ob- 
served in young people. After middle life the tendency to the disease increases 
with age, and Thiersch has sought an explanation of this predisposition in the 
wasting of the connective tissue of the skin in older persons and a subsequent 
lessening of the barrier to the ingrowths from the epidermis. The more 
common development of epithelioma on parts exposed to the air or touch, the 
occurrence of metastasis and the observation of a few cases where secondary 
growths have followed from the contact of the secretions from a cancer indicate 
that it may possess an element of contagion at present unknown. The chief 
recognized factor in the causation of epithelioma may be briefly summed up 
as chronic imtation of some part of the surface tissues predisposed to abnor- 
mal growths of epithelium, sometimes from hereditary influences, but more 
often from conditions acquired by age. A specific parasite will doubtless be 
discovered as time goes on. 

Pathology. — All varieties of epitheliomata have their origin in pre- 
existing epithelium. Briefly stated, there is a proliferation of epithelial cells 
from the epidermis or mucous membrane or from the epithelium of the hair 
follicles or glands. This growth extends downward into tissues where it is 
not normally found and inflammatory conditions are thereby induced. His- 
tologically speaking, two main types may be considered, the lobulated and the 
tubular. The former, which is more frequent, consists of a massing of the 
new growth in the form of lobules, each one of which is composed of con- 
centric strata of cells — from those of the rete to those of the corneous layer. 
Only imperfect cornification can be noted in the innermost cells which from 
pressure form the cell nests or onionlike bodies. In the tubular type, the new 
growth takes the form of cylindric processes which anastomose with each other. 
The cells are smaller than the constituent ones in the lobulated variety, and 
there is no tendency to horny changes or to the formation of cell-nests. Eodent 
ulcer is, pathologically, a tubular epithelioma. All of the so-called micro- 
organisms which have been reported to date appear to be due to cell degen- 
eration. 

Diagnosis. — If the characteristic features of epithelioma are brought to 
mind there will seldom arise any difficulty in diagnosis. The frequent occur- 
rence of epithelioma in or after middle life usually beginning at a site of elec- 
tion, often also of some surface irritation, of a papular or nodular growth, its 
early or late transformation into a chronic ulcer with firm, elevated, everted 
or undermined edges, frequently attended with lancinating pains, are the 



490 PROGNOSIS AND TREATMENT OF EPITHELIOMATA 

distinguishing points. It may need to be differentiated from lupus, syphilis, 
tuberculosis orificialis, verruca senilis and papilloma. 

Lupus vulgaris begins in early life, as a rule, exhibits soft brownish tuber- 
cles, pursues a slow chronic and often painless course, while epithelioma com- 
monly begins in late life, does not develop soft tubercles, may pursue a rela- 
tively rapid course and is usually attended with lancinating pains in the 
ulcerative stage. 

The primary sore of syphilis when situated on the lips or tongue is more 
acute in course and attended with an earlier swelling of the neighboring glands 
than epithelioma. The appearance of the secondar}^ eruption or other signs 
of syphilis would remove all doubt. From the ulcerating syphilide an epithe- 
liomatous ulcer is distinguished by its firm, waxy and elevated edges, single 
lesion and finally by an absence of any tendency to heal and a failure to respond 
to specific internal treatment. 

Ar4uberculous ulcer of the mouth, lips or other orifice may be distinguished 
from epithelioma by its soft border, the presence of miliary tubercles in the 
adjacent mucous membrane and by the evidence of internal tuberculosis. 

Seborrheal warts and papilloma in elderly individuals are not always easily 
differentiated from the early stage of epithelioma, as it is known that they may 
become the seat of the latter. Any induration about the base of a wart in 
senile life, and especially if attended with pain, should arouse a suspicion of 
the development of cancer. 

The characteristic features of rodent ulcer and Paget's disease will easily 
distinguish them from all other forms of skin disease. 

Prognosis. — Superficial epithelioma before the lymphatics are involved 
may be usually cured. After the lymphatics have distributed the seeds of the 
disease and sometimes in the deeper nodular forms, a cure is not to be expected. 
Though some cases are rapidly fatal, many continue without impairment of 
the general health for years. 

Treatment. — The methods employed may be governed somewhat by the 
location and extent of the disease, and often by the facilities at hand. 

Radiotherapy when applied to cases in which there is no involvement of the 
lymphatic system is a valuable therapeutic measure. It is often permanent in 
its effects, especially when used for the rodent ulcer type ; the cosmetic results 
are excellent; and it is a painless method and not tedious. Hyde reports no 
failures among the cases of superficial epithelioma treated by him, and in a 
total of 125 cases' treated with the X-rays, 102 are free from the disease. The 
majority of these were of the rodent ulcer type. This opinion is verified by 
the clinical experience of many observers, both in this country and in Europe. 
The best method includes the use of a medium hard tube at a distance varying 
from four to ten inches, exposures lasting from two to twelve minutes, applied 
every alternate or third day. The whole course of treatment seldom exceeds 
three months. Some few cases of Paget's disease have been reported as cured 
by the X-rays. «. 

Phototherapy has been used by Finsen, Petersen and others with distinct 



TREATMENT OF EPITHELIOMATA 491 

effect on superficial cancer of the skin in the early stages. This method ran 
hardly he said to be superior in any respect to the one just outlined. The 
editor can report that radium-barium chloride with an activity of •.'.">. noo 
caused the disappearance of three cases of discoid epithelioma appearing on 
the mucous membrane of the mouth, of the lower lip and of the palpebral 
conjunctiva. These lesions were of long duration and did not yield to any 
previous method of treatment. The tube containing the radium was applied 
directly to the diseased surface for an interval of live to thirty-five minutes, 
daily, and the number of treatments received was ten, forty-one. and nineteen, 
respectively. From personal observations of over fifty cases of epithelioma 
(not of the mucous membrane) which received radium, in power varying from 
5,000 (French) to 200,000 (German measurement) radio activity, it is safe 
to state that the efficacy of this agent will be greatly increased when a larger 
supply of a definitely known and greater power can be procured. W. 11. King 
has lately been experimenting with celluloid pencils coated with radium. 
These are introduced into the growth and permitted to remain for forty-eight 
hours, then two days are allowed to elapse and the treatment is repeated. As 
yet, nothing definite can be said concerning this method. 

The high-frequency currents have been employed successfully by Pear>"ii- 
and Riviere. The Oudin resonator is the type employed, and the editor has 
seen good results from its temporary use in stimulating epitheliomatous ulcera- 
tions, but never has he observed a cure from this method alone. 

For many cases of epithelioma, topical measures, such as excision, erasion 
and local destructive agents, may be advised. The small superficial forms which 
have begun to ulcerate may be thoroughly scraped with a dermal curette, either 
with or without the previous use of cocaine, the consequent bleeding arrested 
by pressure and the surface covered with piirogallic acid crystals. This causes 
almost immediately a watery exudation from the surface and the appearance 
of a black deposit which later forms a complete crust. This can be allowed 
to remain in place for three to six days, then removed, the parts thoroughly 
cleansed with water as hot as can be borne and the application renewed. If 
irritation arises from this treatment, a simple dressing with aristo^ or nosophen 
powder may be substituted until the irritation has subsided or an ointment of 
pyrogallic acid, ten per cent., may be substituted for daily use. In most cases 
this method of treatment is unattended with pain and if the curette is used to 
scrape away the diseased tissue before each weekly or semi-weekly dressing, it 
is very effective in many cases. If unusual irritation arise pyrogallic acid 
in any form should be discontinued and a simple ten per cent, bori* arid 
ointment employed until all signs of irritation have disappeared. The latter 
ointment may be used also during the process of healing after the destructive 
application is no longer needed. Thuja, one part, to two of fresh lard or 
glycerine, can be employed with good effect in some cases, especially if papillary 
in character. This remedy may be given internally at the same time. Phyto- 
lacca is another substance which may be used locally and internally at the 
same time. For local use the expressed juice of the fresh leaves, which has 



492 TREATMENT OF EPITHELIOMATA 

been allowed to evaporate until it has the consistency of a thick paste, is the 
best form; when not available, a five to twenty per cent, ointment can be 
employed. The diseased surface may be covered with this and allowed to 
remain for eight to ten hours, according to the degree of pain and the endur- 
ance of the patient. Then it may be removed, the surface cleansed with hot 
water and again applied. Under this application healing often begins at the 
periphery and the extent of the application should be reduced as the healing 
progresses. While considerable pain is experienced from the application, it is 
not as severe as from some other methods of treatment. Phytolacca, second or 
third decimal, should be given internally at the same time. 

Arsenic has long been known to have an elective affinity for morbid epithe- 
lial growths, both from external and internal use. One of the best preparations 
is that first suggested by Cerny and Trunecek. This consists of powdered arse- 
nious acid, one part to eighty to one hundred and fifty of a liquid containing 
equaT^parts of absolute ethyl alcohol and distilled water. It is applied in 
the following manner : — The ulcer is cleansed (perfectly with very hot water) 
and if necessary scraped with the curette, bleeding controlled by pressure, 
and the mixture shaken and applied with a brush or cotton wrap over the 
whole surface of the growth. This is allowed to dry; then another layer is 
spread over the part and is repeated daily thereafter. No further dressing 
is required. As a rule, very little pain is felt from this application if the 
weakest preparation is used, which should always be the case with the first 
trial. Occasionally the application causes considerable oedema of the sur- 
rounding parts of the skin, and then should be suspended until the swelling 
has disappeared. The crust which appears from this application is usually 
thin, first yellowish, gradually becoming brown and. finally, black. Later 
the edges loosen and a darkish fluid oozes out from the edges of the ulcer. 
Treatment, however, is continued until the eschar is loosened and non-adherent 
to the subjacent tissue, when it can be easily removed. Then the parts may 
be thoroughly cleansed with hot water and the application renewed. So long 
as a dark crust forms treatment is continued. If only a yellowish crust forms 
it indicates that all the cancerous tissue has been destroyed. In some cases 
the one hundred and fiftieth solution is sufficiently strong for the whole 
treatment, but as a rule the amount of arsenic should be increased first to 
one to one hundred and if necessary one to eighty. When all signs of the 
cancerous tissue have disappeared, the surface may be treated with boric acid 
ointment before mentioned. This application is also effective in some cases of 
epithelioma before ulceration has occurred. As it does not act on corneous 
epithelium a small portion of the central part of the growth should first be 
removed with the curette or scissors, after which the mixture can be used as 
before described. The use of arsenic in this form has the advantage that it 
can be applied by the patient daily if unable to visit the physician at so fre- 
quent intervals. The author and editor have used this method in fifteen cases 
with very satisfactory results ; in one of them the growth first originated on the 
nose and had spread to the lower eyelid. Very often small warty patches of 




Fig. 131— PAGET'S DISEASE 

STAGE OF INDURATION 

Patient is a thin woman of sixty-five. Disease began two years ago as a small 
reddish scaly lesion near the nipple. Within a year small nodules have appeared in 
the skinabout the nipple, the latter has become retracted and more recently a slight 
discharge has occurred from the base of one or more nodules. The glands of the 
axilla are unaffected. Burning sensations have been quite common and often worse 
at night. Cured by the use of conium, third decimal, internally and the local appli- 
cation of a three per cent, fuchsin ointment. 




Fig. 135.— MYCOSIS FUNGOIDES 
Posterior view of the subject depicted in Fig. 134. 



MYCOSIS FUNGOIDE8 199 

or purplish color, and vary in size from a pea to an orange. The tumor- tend 
to group together and sometimes increase or decrease in size m a remarkably 
short time. They are apt to discharge a foul-smelling, Berous Quid, and fre- 
quently they ulcerate and bleed freely. There is, at times, intense itching of 
the skin over and around the tumor as well as in the premonitory eruptions. 
On the development of ulceration, the health of the patient rapidly declines, 
intractable diarrhoea sets in and the exhausted system finally succumbs. 

Etiology and Pathology. — The disease is not known to be contagious 
or infectious. It occurs almost exclusively in adults and more often attacks 
men in middle life. Blanc reported finding in one case a diminution of red 
blood corpuscles and a marked increase in the number of white cells, giving a 
relative proportion of one to one hundred and thirty as compared with the 
normal of one to three hundred and fifty or five hundred. From this and a 
histological study of the growths in this case. Blanc concluded it was probable 
that the disease was related to the lymphatic system. The minute structure 
of these tumors consists of small round cells imbedded in a delicate fibrous 
matrix. It resembles round-celled sarcoma and lymphosarcoma and also the 
infective granulomata. As yet its exact nature has not been determined. 

Diagnosis. — The prodromal eruptions of this affection may resemble the 
more common diseases, such as eczema, psoriasis or lupus crvthematosusu 
Generally the absence of some diagnostic feature of these diseases will afford 
ground for doubt. For instance, patches of eczema are not sharply defined or 
so persistent and usually give rise to more discharge ; psoriasis seeks the ex- 
tensor surfaces and lupvs erythematosus the face; the latter is usually unat- 
tended with much itching, but often with atrophic scarring. 

After the tumor-like growths develop and their variable manner of coining 
and going, etc., is noted, little difficulty will be found in differentiating them 
from other neoplasms of the skin. Multiple pigmented sarcoma is thought 
by some to be closely related if not the same disease. The form of sarcoma, 
however, is not preceded by eczematoid eruptions; pruritus is exceptional and 
the tumors disappear by ulceration and not by resolution, as may be the case 
in mycosis. Syphilitic tumors are not attended with itching, do not stand out 
from the surface so prominently or become pedunculated, and other character- 
istic signs of syphilis can usually be found. The tubercles of leprosy do 
not fungate, itch, or pass through the rapid changes of mycosis fungoides. 
Anaesthesia is apt to be present and is sometimes extensive in leprosy, and 
its ulcers may be deep and disfiguring, moreover its tubercles always con- 
tain the bacillus leprae, which is easily found on efficient microscopic exami- 
nation. 

Prognosis. — This is always unfavorable unless modified by radiotherapy. 
The worst cases, i.e., those without prodromal eruption, have an average dura- 
tion of about two years, but may die in a few weeks. Other cases usually 
prove fatal after a longer irregular course, averaging about eight years. Per- 
sistent diarrhoea and marasmus at the last hasten the fatal issue. 

Treatment. — No local measures have proved of any service in this die- 



500 XERODERMA PIGMENTOSUM 

ease except radiotherapy. Scholtz has reported the cure of three cases in which 
the lesions, both tumors and pre-mycotic foci, have completely disappeared 
under persistent use of the X-rays. Hyde, Lustgarten, Elliot and others have 
reported like results. The pruritus and other distressing complications may 
be treated with soothing lotions and antipruritic applications as outlined under 
the treatment of eczema. After the fungating tumors have developed they 
should be kept clean by washing with hot borax water or a solution of perman- 
ganate of potash, and then dusted over with any non-irritating antiseptic pow- 
der, such as aristol, iodol. nosophen, iodoform, boro-phenate of bismuth, or 
boric acid. Where ulcers form they should be dressed with antiseptic appli- 
cations. Internally arsenic (Fowler's solution) has been given in full doses, 
by the mouth and by hypodermic injection, with benefit and with a. reported 
cure in one case by Kobner. Abscess is very likely to arise from subcutaneous 
medication with arsenic, therefore it should be employed with great caution. 
It is quite probable that a well indicated drug might exert a more curative 
effect. Tonics and a generous diet are usually necessary. 

A clinical history of the disease may suggest some of the drugs named below, 
but each case would need careful individualization in making a prescription. 
See Cal. carb., Kali brom.. Lach.. and Phosphorus. 



XERODERMA PIGMENTOSUM 

(Atrophoderma pigmentosum; Angioma pigmentosum et atrophv um; Melano- 
sis lenticularis progressiva; Dermatitis Kaposi; Liodermia essenlialis cum 
melanosi telangiectasia; Lentigo maligna.) 

Xeroderma pigmentosum is a rare chronic disease of the skin that be- 
gins in early childhood and slowly passes through various forms of erup- 
tion that terminate, sooner or later, in some form of cancer. The disease 
seems to have a hereditary basis as shown by its frequent occurrence in certain 
families. As the disease appears principally upon those parts that are ex- 
posed to light, the face, neck, hands, arms and legs, it has been suggested 
by Unna that it is due to the action of sunlight upon a hereditarily sensitive 
skin. He points out the analogy between this disease and the so-called cancer 
of sailor's skin. 

Xeroderma pigmentosum commences in the first or second year of life as a 
diffuse or mottled redness of the face, neck and back of the hands, together with 
a roughening of the skin due to increase of the horny layer. The hypersemic 
patches are succeeded by small pigmentations like freckles, among which small 
telangiectases also appear. Taylor claims that these lesions are variable, dis- 
appearing at one point and appearing at another, but always increasing in 
number. About the sixth year of life, small areas of atrophy appear, which, 
according to Taylor, correspond to previous freckles or telangiectases. The 
atrophic areas increase in size, forming patches of thinned, shrunken, dry, 



XERODERMA PIGMENTOSUM 501 

white skin (parchment skin or seroderma) . At the margin of the atrophies, 

the telangiectases are prominent and may form angiomatous nodules. Alter 
B period of from two to ten or even more years warty nodules appear, that 
resemble moles both to the naked eye and in their minute structure. I 
nodnles form the starting point of the malignant growth. They grow larger, 
usually ulcerate and may bleed freely. On the appearance of the tumors, the 
patient's health rapidly fails and death from the cancerous cachexia occurs in 
two years or less. Metastases to the lymph glands or internal organs have not 
been observed. These final tumors have been variously described as Barcomata, 
myxosarcomata and carcinomata. Unna claims that they are all carcinomata, 
stating that the early growths, like simple naevi, are sometimes strikingly like 
sarcomata and liable to mislead the observer unfamiliar with the appearance of 
naevi. This disease reaches its fatal termination in from five to fifteen pears, 
though a few cases have reached the age of twenty-five and even sixty years. 
About one hundred cases have been reported. 

Etiology. — The causes of this disease are obscure. It seems probable 
that some congenital defect exists in the skin (as in ichthyosis) on which the 
normally stimulating sunlight produces abnormal effects, progressive in nature. 
While the actual disease is not hereditary there may be a defect in the develop- 
ment of the sMn due to hereditary influences. It is supposed by some to he a 
tropho-neurosis. The disease more often begins in summer, anil at about the 
age when children are first liable to have the uncovered parts of the skin ex- 
posed to direct sunlight. 

Diagnosis. — In a well developed case no error in diagnosis is likely to 
occur. The location on the exposed parts of the skin, the pigmentations, 
dilated capillaries, atrophic spots and warty growths are sufficiently char- 
acteristic. At an early stage the lesions may resemble the eruption of measles, 
erythema from exposure to the sun. ordinary freckles, vascular rum or urticaria 
pigmentosa; but the persistent though perhaps erratic course, limited distri- 
bution, absence of subjective sensations or some other equally apparent dif- 
ferences would sooner or later serve to exclude all these affections. The 
atrophic stage of scleroderma, and xeroderma pigmentosum after atrophy has 
begun, may present an objective similarity, but in no other way. Scleroderma 
begins later, is not limited to the face, neck and hands, and the signs of atrophy 
are preceded by those of hypertrophy, stony hardness, "hide-bound skin," etc., 
distinctly unlike the evolution of xeroderma. 

Prognosis. — This is always unfavorable after the disease is fully developed. 
In the earlier stages the progress of the disease may probably be delayed, life 
prolonged and possibly cancerous growths prevented by treatment. 

Treatment. — No therapeutic method has been found curative as yet. 
Internally, an indicated remedy should be selected from among those known to 
stimulate the nutrition of the skin. Externally, in the early period of the dis- 
ease, the surface may be protected so far as practicable from the sun's rays 
and other irritants. Later conditions may be treated as they arise: when the 
eyes are affected the conjunctivitis may be relieved by frequent bathing with a 



5Q2 VERRUGA 

saturated solution of boric acid. The growths may be removed by excision 
or. the galvano-cautery, as the wounds thus made heal rapidly. Old ulcers may 
be made to heal by scraping with a sharp curette and dressing with a mild 
antiseptic ointment, while new sores may be dressed at once with the latter; 
Crocker recommends a dilute ammoniated mercury ointment for this purpose. 
The Rontgen rays have cured the ulcerations of this disease and may be re- 
garded as a possible method of treatment. 



VERRUGA 

(Verruga bland; V. mula; V. de Zapo 6 de quinua; V. de Costilla; V. de 
Sangre; V. Andecola; Oroya fever; Carrion's disease; Peruvian and An- 
dean warts.) 

Verruga is a chronic infectious disease characterized by a specific erup- 
tion. It is confined to certain parts of the Pacific slope of the Peruvian 
Andes, and attacks both natives and foreigners who pass through its en- 
demic localities. 

The disease begins some weeks after infection, with fever and considerable 
pain in the muscles, bones and joints. After the lapse of several weeks or 
months, or even a year, according to one observer, the eruption appears in the 
form of small, fleshy protuberances, called " warts." that grow to the size of a 
cherry or even an orange. The typical appearance of the eruption is first upon 
the head and progressively downwards, appearing on the mucous and serous 
membranes as well as the skin, and some may be subcutaneous. The surface 
tumors are very painful; they ulcerate readily and bleed freely. After a 
variable period, running into months, the lesions undergo involution and leave 
no mark, unless sloughing and iilceration have occurred. 

The prognosis is uncertain. Some cases recover, but the mortality rate 
is from six to ten per cent, among the natives and from fort}' to ninety per 
cent, among the whites. One attack affords no immunity against future at- 
tacks. 

Etiology and Pathology. — The disease is transmissible by inoculation 
and attacks both sexes at all ages. Laborers and other workers in the earth 
are especially liable to infection. Moisture, warmth and malaria seem to be 
factors in the aggravation or production of this disease. Histologically, it is 
composed of round cells in a delicate fibrous matrix, resembling a lymphosar- 
coma or the infective granulomata. Yzquierdo has found, in the tumors and 
neighboring blood-vessels, a bacillus that- has specific staining qualities. Other 
micro-organisms have been found, but none can be absolutely determined as 
the effective agent. The disease has been transmitted by inoculation of the 
tumors, but not by a culture of the bacillus. 

The diagnosis of verruga in the pre-eruptive stage may be difficult; 
rheumatism, the pains of syphilis, and malaria may need to be excluded. A 






VERRUGA &08 

history of travel or residence in an endemic district would be significant. After 
the eruption appears the disease is easily recognized. 

The treatment is based on general physiological principles, such as re- 
moval from the infected region, a sustaining diet, etc. No drug specific is 
known, but Cundurango, Kali brom., Lack., Petro., Phos. and Thuja show 
some points of similarity in their pathogenesis. 



PART III 

INTERNAL THERAPEUTICS 



ACONITUM 



Aconite, acting on the cerebro-spinal axis, has a paralyzing effect on the 
arterial capillaries which may result in rapid congestion and inflammation, 
especially of the serous, sero-fibrous. mucous and cutaneous tissues. Mento- 
nervous symptoms of fear, anxiety, restlessness and peripheral neuralgic pains, 
or sensations of heat, numbness, tingling, stinging, biting, itching, tearing, 
drawing, crawling, etc.. with great sensitiveness to cool air and touch are char- 
acteristics. It is adapted to the early stages of several angioneurotic and 
neurotic affections of the skin. 

Erythema multiforme. — Spots like flea bites on hands, like nettle rash on 
back of hands ; red spots on face ; discolorations on limbs ; with heat, stinging, 
pricking or itching sensations; with restlessness; with fear or anxiety about 
attack; in plethoric persons, especially when following anger, chagrin or 
fright with reactive faintness and prostration. 

Pruritus. — Of recent occurrence in persons of full habit excited by mental 
emotions, with fear that some severe eruptive disease is about to appear. 
Sensations of heat, biting, tingling, crawling or fine prickling; worse on ex- 
tremities and face, at night, from tobacco, and relieved by stimulants. 

Urticaria. — Attended with mrasually sharp pains, great restlessness and 
anxiety about attack or something connected therewith, with lesions of large 
size, distinctly red and hot. 

Herpes zoster. — Prevesicular stage attended with fever and sharp neuralgic 
pains, due to exposure to cold air, suppressed perspiration or depressing emo- 
tions, especially in the plethoric of sedentary habits. 

Aconite may be given in the sixth decimal attenuation for sensory affections, 
and in the same or lower attenuation for a more distinct, congestive or inflam- 
matory disorder. 

AGARICUS 

This drug acts primarily on the nerve centres and causes contractions of 
involuntary muscular tissue, especially of the capillaries, stimulates secretions 
and leads to local congestions and oedema. The effects produced on the skin 
through the motor and sensory nerves arise chiefly from local disorder of the 



AGNUS CASTUS 506 

circulation and the secreting glands. Circumscribed erythematous, papular, 
pustular and cedematous lesions are the principal objective effects, tiensaiions 
of itching, burning (as from frost-bites), formication and twitching (some- 
times seen) may be felt. Locations principally affected are the face, ears, bead, 
back, hands, fingers, toes and genitals. 

Acne simplex of the face, or face and back, accompanied with an oily con- 
dition of the surface, a darkish-red areola about the papules or pustules in 
contrast with the rather pale, unaffected parts of the skin, frequently calls for 
agaricus. Special indications for it are muscular twitchings (choreic), burn- 
ing, crawling, or creeping sensations. 

Acne indurata less often requires agaricus (on similar indications) unless 
associated with rosacea. 

Seborrhcea oleosa occasionally requires agaricus when there are on the 
face contrasting spots of purplish redness and undue pallor, red ears, muscular 
spasms, burning, creeping sensations. 

Hyperidrosis of the legs, especially of the inner surfaces, worse at night 
and accompanied with sensations of coldness as if fanned, lassitude or weak- 
ness, twitching, etc., may be cured with agaricus. 

Erythema calorica (pernio; chilblains). — Eedness of face, with twitching 
and burning as after freezing; of fingers, with burning itching as \i frozen; 
redness without heat; itching of fingers, toes and ears, with burning, redness 
and swelling as after a frost-bite; with sensations worse from heat and 
scratching. 

Erythema multiforme with above indications. 

Angioneurotic oedema. — Eedness and circumscribed swellings without 
heat; burning and tension as from frost-bite, on or about the face, hands or 
genitals, with twitching of superficial muscles. 

Rosacea. — Redness and oily appearance of the nose or cheeks with little or 
no heat ; at a later stage bluish redness of nose like frost-bite with paleness of 
unaffected skin, worse after eating, from exposure to cold and mental applica- 
tion; papulo-pustules on cheeks and forehead, associated with muscular twitch- 
ing of face or spasmodic affections elsewhere, flatulent indigestion or genito- 
urinary disorders. 

Agaricus should always be given in the lower attenuations, first to sixth 
decimal, according to the response obtained. 



AGNUS CASTUS 

This drug may be found useful in skin disease associated with sexual impo- 
tence in either sex, and attended with mental depression. 

Eczema, Psoriasis. — With the above indications. 

Pruritus. — When associated with sexual neuroses and general weakness, 



50ti ALOES— ALUMINA 

sometimes coldness of external genitals, with sensations like flea bites or corro- 
sive itching, only temporarily relieved by scratching ; in the prematurely old. 
The sixth decimal attenuation is most frequently employed. 



ALOES 

This drug is adapted to indolent and phlegmatic types and to conditions 
occurring in middle life or old age. The symptoms are usually worse from 
heat, from walking, and after eating. The characteristic cystic or hepatic 
symptoms are especially valuable as indications. 

Acne indurata, with varying redness of the face and reflexly duo to pelvic 
engorgement, especially when associated with a frontal headache, plug-like con- 
stipation, or other symptoms of aloes. 

Keflex types of eczema situated on the inner part of thighs, perineum and 
about the anus or vulva when due to pelvic engorgement, especially of the 
rectum, are often benefited by aloes. The symptoms are usually worse from 
heat, dampness, in the morning — between one and ten a.m. — from walking and 
after eating. It is adapted to indolent and phlegmatic types and to conditions 
of middle or old age. Characteristic rectal, cystic or hepatic symptoms are of 
special value as indications. 

Both the low and high attenuations have proved efficient. The author 
prefers the twelfth decimal. 



ALUMINA 

This drug probably produces its effects on the tissues through the motor 
nerves. It is indicated in chronic skin affections attended with dryness and 
tension. Symptoms connected with associated catarrhs of the mucous mem- 
brane, mental depression and peevishness furnish other indications for this 
drug. Its characteristic constipation is a keynote for its use in cutaneous 
diseases. 

Partial anidrosis or asteatosis should lead to a study of alumina, particu- 
• larly in old age, when there are sensations of tension or intolerable itching, 
worse at night in bed. 

In acne simplex, associated with general or local dryness and tension of 
the skin and mucous membranes, consequent dry constipation, soreness in 
rectum and a feeling like an emission when straining at stool, particularly 
when the papules or pustules are surrounded with little or no redness, alumina 
is often curative. 

Alumina may be indicated in chronic skin affections attended with dryness 
and tension. These conditions occasionally characterize a more or less general 



AILANTHUS— AMMONIUM CARBONIC I M 



.,ii7 



and persistent eczema occurring in thin and poorly nourished subjects, 
daily in youth and old age. In such persons the inflamed skin may appear 
thin rather than thickened, hence scratching causes it to bleed easily, [tching 
is worse at night and from warmth of bed. Nearly always associated catarrhs 
of the mucous membranes, mental depression and peevishness furnish other 
indications for this drug. Its characteristic constipation is a keynote for its 
use in cutaneous disease. 

Alumina may be indicated in mild cases of ichthyosis, and in that rare 
disease sclerema neonatorum. 

Prurigo. — In early stages, itching rash without redness on arms and legs, 
intolerable itching, worse on becoming heated, from warmth of bed; dryness of 
whole skin, associated with characteristic constipation or affections of mucous 
membrane. 

Alumina can be given in the sixth decimal or higher attenuation. 



AILANTHUS 

This drug produces a toxic effect on the system, with disturbances of the 
gastro-intestinal tract, malaise, torpor, weakness, restlessness, low fever and an 
outbreak on the skin resembling severe types of scarlet fever or measles. 

Erythema scarlatiniforme. — In cases preceded or accompanied with un- 
usual depression, fever and a dark red or livid colored rash. 
The second decimal is a suitable attenuation. 



AMMONIUM CARBONICUM 

This salt disorganizes and thins the blood so that putrefactive processes, 
local congestions and hemorrhages occur, the vital powers are enfeebled, and 
reaction to normal stimuli lessened. On the skin erythematous, papular, 
pustular, vesicular lesions and desquamation have been noted. The principal 
locations have been the face and upper half of body. Sensations of heat, itch- 
ing, burning, tension and soreness to touch, with aversion or sensitiveness to 
the open air, stormy weather, bathing; and corresponding relief from dry 
weather and remaining indoors are characteristic. 



Acne simplex or indurata may suggest ammonium carb. when the lesions 
are of a recent date, attended with sensitiveness, contraction or tension of the 
skin of the face, great sensitiveness to touch, especially when there exist asso- 
ciated catarrhs, or if the patient is suffering from a sort of listless debility, 
whether due or not to recent illness, and the modalities of this drug are 
found to be present. 

Erythema scarlatiniforme. — Eedness like scarlatina of whole part of 



508 AMMONIUM MURIATICUM— ANACARDIUM 

body, with sensitiveness to cold, desquamation and exfoliation of the skin; in 
cases due to absorption of putrefactive matters; with sensations of swelling 
(tension), heat or itching. 

This drug is adapted to acute or subacute forms of eczema due to blood 
changes, particularly to erythematous eczema of the face, attended with heat, 
itching and tension. There are usually present symptoms of debility, sensitive- 
ness and aggravation from cold or stormy weather, open air, after eating and 
while at rest, with corresponding relief from warm, dry weather and indoors. 
There may be associated catarrhs of the mucous membranes with their char- 
acteristic symptoms, tendency to hemorrhages, etc., affording concomitant 
indication for this remedy. 

The lower attenuations are to be preferred ; third to sixth decimal. 



AMMONIUM MURIATICUM 

This drug increases the fluidity of the blood, promotes glandular secretion 
and causes nodular swellings. When the sweat is increased vesicles are apt 
to appear on the face, hands wrists, chest, neck, or other parts; or in a more 
generalized miliary rash of a mild grade with erratic itching, stinging, burning 
or crawling; worse in the evening, — better on lying down and from scratching. 

Miliaria sudamina, Miliaria rubra. — Acute affections of the sweat glands 
often require only ammonium mur. to effect a rapid cure if any of the above 
indications are present, so well does it fit the primary functional disturbance. 

Seborrhoeic dermatitis beginning in warm weather from excessive sweat- 
ing of the parts may present early symptoms like ammonium mur., and at that 
stage yields quickly to its curative action. 

Erythema nodosum. — Deep-seated reddish-brown sensitive nodes around 
wrist, with itching ; seem about to suppurate, but do not ; with drawing tension 
in legs when sitting or lying; with burning, stinging or crawling sensations; 
in fat or sluggish young persons, or fat in body and thin in extremities ; in the 
poorly nourished, anaemic or rheumatic. 

Ammonium mur. should usually be administered in the third decimal at- 
tenuation freshly prepared. 

ANACARDIUM 

Mental irritability and illusional depression characterize this drug. These 
symptoms, the plug-like sensation of pressure and sometimes sexual weakness 
are fine indications for it in suitable cases of neurotic eczema with papular, 
papulo-vesicular and pustular lesions, often widely distributed. Morning and 
late evening aggravations of the itching and burning sensations are character- 
istics. The warmth from close-fitting clothing seems to excite itching, and 



ANTHRACINUM— AN'TIMOMl M (HI 1)1 M 509 

scratching affords little or no relief Erom the latter sensation. Sum,- of the 
lesions produced on the skin by this drug, as well as the sensations, correspond 

pretty closely with the eruption of lichen planus. One case m the author's 
care improved rapidly while under treatment with the third decimal adminis- 
tered everj three hours. Relief of the surface irritation was almost coincident 
with an abatement of the mental symptoms which first called up this remedy. 
Anacardimn may be compared with rlius to\. in its action 00 the cutaneous 
structures, but it occupies a very much narrower space in the therapeutic Held. 

The third or sixth decimal has been found to be most often curative in 
effect on the skin. Occasionally the dose may need to be lowered to the tincture 
before a satisfactory result is witnessed. 

ANTHRACINUM 

Furuncle. — Blue boils with burning pains. Carbuncles hard and pointed, 
with severe burning pains, exhausting perspiration, cerebral symptoms and 
expectation of death. Especially for carbuncles situated on face or head. 

Anthrax maligna. — Horrible burning pains in hard pointed lesions, not 
relieved by arsenic; red lines mark course of lymphatics. Signs of blood poi- 
soning, gangrenous sloughing with extreme exhaustion and cerebral symptoms. 

The thirtieth decimal or higher attenuation should be employed. 

ANTIMONIUM CRUDUM 

This drug acts chiefly upon the skin and mucous membrane, lowers vitality, 
increases the secretions without producing much inflammation; sweat without 
odor, general or symptomatic, intermittent, macerated, inflamed and wrinkled 
skin from excessive sweating, especially indicated for affections due to excessive 
sweating or for sweat rashes on the face, neck, back, chest, wrists, etc. If the 
special indications for antimonium crud. — irritable disposition and white 
tongue — are present it will nearly always benefit sweat diseases. Aggravations 
from exercise, warmth and wine, and relief from rest and cool air, still further 
point to its adaptability to these disorders. 

Acne indurata may occasionally be benefited by antimonium crud. when 
with its other characteristics there are present small red papules, which sting 
when pressed, particularly in cases associated with gastric derangements and 
in the alcoholic or dissipated. 

Symmetrical hyperidrosis of the feet or hands without odor, sometimes 
causing the skin to look macerated and wrinkled, especially when associated 
with the catarrhal diathesis, may be relieved by antimonium crud. 

In miliaria rubra (from sweating) on the neck. late. back, chest, wrists, 
etc., with stinging and itching sensations, worse from exercise, warmth, wine, 
and relieved by rest and cool air, antimonium crud. not only gives immediate 
relief, but tends to prevent a recurrence. 



510 ANTIMONIUM CRUDUM 

Hydrocystoma and hydradenitis suppurativa, rare affections, probably 
present in some cases good indications for antimonium crud., and then would 
respond to its action. 

Subacute eczema about the nostrils and mouth, due to or associated with 
nasal catarrh, will often improve rapidly under the influence of this remedy, 
sometimes even when other indications for it are not pronounced. With the 
well-known symptoms of this drug present it may be given confidently for 
eczemas of a low type tending to pustulation and the formation of offensive 
crusts, particularly of the face, ears and eyelids and on or about the genitals. 
It acts better on the fat rather than on the lean in flesh, and on the left side 
more than on the right. Aggravations from cold water, externally and inter- 
nally, from wine, after eating, from touch and motion; relief from rest and 
the open air, a white coated tongue and mental states of fretfulness or sulki- 
ness^are among the symptoms pointing to its selection. Antimony is oftener 
indicated for the eczemas of childhood, but not less useful in similar types of 
youth and mature life. Bluish or brownish staining of the skin remaining 
at the sites of previous lesions (berberis) is a minor indication. 

The apparent influence of antimony in stimulating abnormal epithelial 
growth, and its elective affinity for the feet and hands as manifested in hyper- 
trophic spots resembling callosities and corns, led to its being prescribed 
for an affection now known as keratosis palmaris et plantaris. It has been 
found to correspond symptomatically with the natural history in a number of 
cases of this unusual disease, beginning with the sweating of the hands, tend- 
ency to accumulate flesh, aggravations from cold water, motion and pressure, 
etc. Several cases have been cured, some of them very pronounced and others 
of long standing (twenty years in Gourzale's case). 

Urticaria. — Pimples as from stings of insects, especially on face and about 
joints, with itching waking one from sleep, after rubbing like mosquito bites ; 
associated with perspiration; appearing after active exercise or use of stimu- 
lants ; with irritability, white coated tongue and catarrhal affections. 

Impetigo. — Pustules here and there, preceded by sweat, tingling or numb- 
ness ; associated with gastric disorders and mental irritability. General symp- 
toms worse from stimulants, after eating, exercise and warmth, better from 
rest and in the open air. 

Impetigo contagiosa. — Superficial suppurating and crusted lesions about 
mouth and nostrils, with sore cracks at the corners ; white tongue ; peevish and 
fretful children who do not wish to be touched or observed. 

Verruca, Clavus, Callositas. — Tendency to the development of flat warts, 
corns or calluses on hands or feet, associated with sweating of parts, tingling 
or numbness and other indications for antimony. 

Antimonium crud. should seldom be given above the twelfth decimal. Often 
the lower attenuations will be more efficient. 



ANTIMONIUM TARTARICUM— AVIUM KIM 511 



ANTIMONIUM TARTARICUM 

This drug stimulates the secretions, especially of the mucous membrane and 
the skin, depresses the functions of circulation and respiration, and causes nau- 
sea, faintness and prostration. On the skin it gives rise to papules, vesicles and 
pustules, the latter being characteristic and occurring on the mucous membrane 
also. Location of lesions is not characteristic and sensation is not a constant 
symptom, though tickling, itching, crawling and burning are credited to it. 

Acne simplex or indurata with a predominance of quickly formed pustules 
with deep red areola, more numerous on the shoulders, back of neck and back, 
leaving stains and pock-like cicatrices at the site of earlier lesions; are good con- 
ditions for antimonium tart. Persistent desire for acids or alcoholic stimulants 
and eruptive lesions of the mucous membrane are special indications. As this 
drug acts both dynamically and locally, it may be employed externally, one to 
two hundred, in ointment or dusting powder in cases requiring local appli- 
cations. 

Hydradenitis suppurativa has pathological features corresponding to 
antimonium tart. It is quite likely, therefore, that its internal and local 
employment would hasten recovery from this disorder. 

Herpes gestationis, Impetigo herpetiformis and Dermatitis herpeti- 
formis are rare affections which might present indications for antimonium 
tart, by widely distributed and extending vesicular eruptions, by first appearing 
on inner thighs, by transformation to pustular lesions and the presence of other 
characteristics of this drug. 

Impetigo. — Discrete vesico-pustules or pustules surrounded by a red areola, 
sometimes umbilicated, especially on face leaving bluish marks; weak and ill- 
humored subjects. Symptoms generally worse from perspiration, and better 
in the open air. 

Impetigo contagiosa. — Large split, pea-sized, painful pustules with red 
areola ; bulky yellow crusts ; numbness, itching or tickling sensations. 

The third decimal is the most useful attenuation in the above affections. 



ANTIPYRINE 

This synthetical product introduced into the system acts especially on the 
vaso-motor centres, causing dilatation of the capillaries of the skin and conse- 
quent circumscribed patches of hyperaemia and swelling resembling some of 
the lesions of erythema multiforme or urticaria. The favorite locations for 
eruptions are the chest, back and abdomen, but they may appear on the extremi- 
ties; they are more abundant, as a rule, on the extensor surfaces. The color 
disappears on pressure, except that a brownish tinge often remains. The onset 
is attended with itching and often with sweating. 



512 APIS 

Erythema multiforme. — Bed, slightly elevated spots on trunk or begin- 
ning on trunk and extending to limbs ; with cold sensation inside of body ; with 
abundant perspiration ; from gastro-intestinal irritation or from effects of some 
article of food. 

Urticaria. — Eruption appears and disappears suddenly with intense itch- 
ing; on chest, back, abdomen or generalized, with intermittent internal cold- 
ness; from intestinal irritation or some article of food. 

Urticaria pigmentosa. — Early stage when lesions appear and disappear 
suddenly, leaving pigmentations; recurring and spreading from trunk down- 
wards to extremities ; onset attended with itching. 

Angioneurotic oedema. — Sudden swellings which disappear, and reappear 
soon upon some other region of the surface ; with nausea, vomiting, suffocation, 
indicating involvement of mucous membrane. 

.^Antipyrine needs to be given in the second decimal for its best curative 
effect. 

APIS 

This poison probably produces its effects by first paralyzing the vaso-motor 
nerves controlling the capillary circulation in certain areas of the cellular tissue, 
resulting in the formation of erythematous and oedematous lesions, and some- 
times resembling the early stages of destructive or malignant forms of inflam- 
mation. Cutaneous eruptions may be generally located, but show a preference 
for the face and extremities. Sensations of stinging, burning, smarting, prick- 
ing, itching, or great sensitiveness to touch are characteristic. All symptoms 
are apt to be worse about 5 p.m., and from heat of bed, and are relieved by cold 
bathing of the parts. "Weakness, stupor and absence of thirst are suggestive 
concomitants. 

Erythema multiforme or nodosum. — When swelling is out of proportion 
to the redness ; with stinging, burning, smarting or great sensitiveness to touch, 
relieved by cold applications; with lassitude, apathy and feverishness without 
thirst. 

Vaccination eruptions. — When occurring within the first three days of 
vaccination, or at a later period from mixed inoculation through the vaccine 
wound, in either case with lesions resembling erythema multiforme, urticaria, 
erysipelas, cellulitis, furunculosis or gangrene and attended with other indi- 
cations of apis. 

Prominent features of its pathogenesis (drowsiness, oedema, etc.) are veri- 
similar to conditions found in oedema neonatorum, and it ought to prove 
remedial in that rare disease. 

Urticaria. — Eed and white blotches and wheals sensitive to touch with 
stinging, burning pains; worse from heat, scratching, better from bathing with 
cold water; feverishness without thirst, apathetic before or between crops of 
eruption. 



ARGENTUM NITRIC1 \i 518 

Angioneurotic oedema.— Large swellings of every form and location, which 
appear rapidly and suddenly shift location on skin or mucous membranes, 
associated with other symptoms of apis. 

Insect bites.— Swellings after bites, sore and sensitive to touch, burning, 
stinging pains, relieved by cold bathing; lassitude, sleepiness and thirstiest 

Furuncle, Carbuncle, Dissection wounds.— Early stage attended with con- 
siderable swelling, burning, stinging, great sensitiveness to touch, weakness 
and dullness. Later stage when swelling extends, accompanied with sting- 
ing, etc. 

Erysipelas. — Pale red cedematous swelling on face, head or extremities; 
stinging, burning, pricking sensations in parts; fever without thirst, apathy. 
Aggravations in late afternoon, from heat of bed, some relief from cold bath- 
ing of parts. 

Lupus erythematosus. — When the disease extends by erysipelas-like at- 
tacks, with considerable swelling from infiltration of cellular tissues, attended 
with stinging, burning or itching sensations, relieved by cold bathing of the 
parts. 

Leucokeratosis buccalis. — Persistent scalded sensation on tongue or other 
parts of the mouth. Dry, sore, cracked tongue in spots or lines, with burning 
and stinging sensations, relieved by cold w r ater. 

The third decimal is the best single attenuation of apis, but occasionally it is 
needed in the first or second, and sometimes in the tincture. 



ARGENTUM NITRICUM 

Nitrate of silver disorganizes the blood, irritates and inflames the mucous 
membranes, deranges nerve function and secondarily or remotely causes disturb- 
ances in the skin (excluding the actual deposit of its granules therein). Its 
place as a remedy in cutaneous diseases is. therefore, limited to affections asso- 
ciated with its characteristic action. Papular and pustular (or ulcerating) 
lesions, dark red or bluish or surrounded with a like-tinted areola, are only 
characteristic. Location is not important. Sensations of splinter-like pricking 
or stinging are the most significant subjective symptoms, though itching is 
occasionally prominent. 

Acne simplex occurring in young persons suffering from neurotic affec- 
tions (epileptoid, melancholic, etc.), affections of the mucous membranes, which 
reflexly cause intermittent flushing of the face, may be benefited by argentum 
nit. Craving for sweets, aggravation of symptoms at night, from warmth, cold 
food, and after eating, and relief from fresh air, are further indications for 
this remedy. 

Acrodynia, Pellagra. — Some similarity in the general and cutaneous symp- 
toms of these autotoxic affections to the pathogenesis of nitrate of silver would 
indicate that it might be of value in their treatment. 



514 ARNICA 

Ecthyma. — Large pustules preceded by itching or pain ; lesions with black- 
ish crusts, surrounded by a dark red or bluish areola, pricking or stinging sensa- 
tions, worse at night and from warmth, better in the fresh air. 

Syphilis. — Primary lesion; moist, painful pimple, changing to an indu- 
rated papule with pricking sensations, worse at night and from warmth. Late 
secondary or tertiary stage with lesions involving the periosteum, with painful, 
sensitive or splinter-like pain, worse at night and from warmth. 

Argentum nitricum is serviceable, when indicated, in the third to sixth 
decimal, never higher. 

ARNICA 

Arnica acts primarily on the blood and leads to local disturbances of nutri- 
tion, hemorrhages, and a peculiar sensitiveness of the peripheral nerves. Its 
very common use for mechanical injuries and myalgic affections has probably 
led to its neglect as a remedy for cutaneous disorders. Clinically it has been 
found that symmetry is a good indication for arnica, and in cutaneous erup- 
tions this has been verified many times. 

Acne indurata characterized by symmetry in distribution and large, deep- 
seated papules or pustules with darkish areola, unusually sensitive to pressure 
(this symptom may be general also), with paleness of the unaffected parts of 
the face, is likely to be benefited by arnica. 

Erythema traumaticum, E. caloricum, Dermatitis venenata, D. calorica, 
D. traumatica. — In any of the foregoing arnica may be indicated by great 
sensitiveness to pressure, bruised sensation, burning, throbbing, stiffness, infil- 
tration and swelling, dark red or livid redness, tendency to hemorrhages or 
gangrenous changes. 

Erythema multiforme. — Eedness. with heat and oedema ; red patches, with 
swelling, soreness and burning ; erysipelatous, with turgescence, heat and papu- 
lar elevations ; especially symmetrical erythema of the face, dorsum of hands or 
feet, with sensitiveness to pressure (lying on) of all or parts of the surface, 
with stinging, burning or itching sensations. 

The form of eczema usually calling for this drug is the erythemato-vesieular 
or papulo-vesicular, bilateral in distribution, often located on the feet, ankles, 
legs, scrotum or arms. Occasionally the form is seen in the gouty or rheumatic, 
and then the erythematous field for closely situated vesicles or papules is well 
marked. Soreness with burning and itching may be present in greater or less 
degree, and not infrequently an early morning aggravation is experienced. 

In psoriasis a more than usual soreness, burning or itching, and symmetry 
in size and distribution of the lesions, are most important indications for 
arnica. 

When inflammatory lesions assume a low type, as when some of the exan- 
themata eruptions pass into the conditions known as dermatitis gangrenosa 
infantum, arnica is always to be considered in selecting a remedy. The local 



ARSENICUM ALBUM 516 

changes in the blood and its vessels, the oedema, sloughing and the disturbance* 1 
in sensation may be verj similar to the more pronounced effects of thai drug. 
Curiously enough the higher attenuations appear to act best in such cases, 
while in eczema and psoriasis the lower have proved most efficient. One of 
my own cases of extensive and protracted psoriasis in which arnica was indi- 
cated yielded only to drop doses of the tincture, and was finally cured with this 
preparation alone. 

Dermatalgia. — Bilateral, bruised, tensive, drawing or tearing pain with 
great sensitiveness to pressure of bed oil lying down; worse from wine, during 
day, better from motion and at night. 

Acrodynia, Pellagra.— Arnica is worthy of study and trial in the thera- 
peutics of these obscure affections. 

Purpura. — Preceded or attended with bruised, sore, weak sensations in the 
parts affected, sometimes moderate hemorrhages from the mucous surfaces, 
with sinking of strength and general sensitiveness of whole body to pressure. 

Peliosis rheumatica. — With bruised pain and sensitiveness of whole body; 
dark red or bluish spots over or near joints of extremities and rarely elsewhere, 
with pains in the joints, languor, anorexia, prostration and moderate fever. 

Diabetic gangrene. — From slight wounds, bruises or contusions, or arising 
spontaneously, preceded by bruised soreness, tension or sensitiveness of the skin. 

Furuncles. — Many small boils, symmetrically distributed; extremely sore, 
hot, hard, bluish-red and shining; less painful after suppuration. Sensitive- 
ness of whole body to pressure, general lassitude. Bruised, pricking, throb- 
bing, burning, stitching sensations, worse from uncovering, rest, cold and some- 
times from warm applications, better from wrapping up, motion, general 
warmth, after midnight and during day. Especially in diabetes. 

Erysipelas. — Bed, hot, cedematous, shining skin, with a tendency to a 
formation of vesicles, bullae, petechia? or ecchymoses. Extreme tenderness or 
soreness on pressure; throbbing, burning, stitching, pricking sensations; worse 
from uncovering, better from warmth and during day. 

Erysipeloid. — Spreading, livid redness from the site of a small wound, 
attended with burning and prickling sensations ; ivorse from cold applications, 
better from warmth. Gangrenous appearance of wound. 

The second to twelfth decimal attenuation of arnica may be used for most 
cases, the higher attenuations being selected for the more typical cases. Some- 
times a lotion of the second decimal may be used with benefit. 



ARSENICUM ALBUM 

Practically it is impossible to draw any strict lines about this drug in giving 
it place in the therapeutics of skin diseases. Prescribed empirically or with- 
out careful review of its wide field of action, it most often yields disappoint- 
ment, whatever the dose employed. It may be occasionally indicated in a large 
number of cutaneous diseases, but commonlv only in a few. Then some of its 



516 ARSENICUM ALBUM 

characteristics should be found as prominent or typical symptoms. These in 
the order of their relative value as therapeutic points in skin affections may be 
placed as follows : burning with or without itching sensations, worse at night 
(at rest), from scratching and from cold, often relieved by warmth or motion; 
periodicity in the onset and aggravation of eruptions or of associated symptoms 
(restlessness, thirst, etc.) ; chronicity — even malignancy in the sense that the 
disease is irresponsive to treatment or low in grade; adynamia and continuous 
or manifested by intermittent periods of exhaustion. The latter condition, so 
valuable as an indication for arsenic in some acute affections, is rarely observed 
in true affections of the skin excluding the eruptive fevers ; on the other hand 
it may prove a curative remedy for cutaneous disease even when the general 
health appears unaffected. 

Arsenic acts with apparent directness on the deeper cells of the epidermis, the 
sites^of a multitude of nerve terminations, causing a proliferation of immature 
cells, irritability of the affected parts with great intolerance to artificial stimu- 
lation. Earely the process may go on to vesiculation, pustulation, ulceration 
or gangrene, but the eruptions commonly calling for arsenic are dry and scaly. 

In acne of the face in youth or adult life arsenic is only rarely indicated, 
and then only by the presence of its characteristics already named, particularly 
by a marked intolerance to local stimulation of the affected skin. 

Eczema of the squamous type presenting some of the characteristics of 
arsenic may be frequently cured with this remedy. Such eczemas are more 
often located on the face, ears or scalp, and occasionally an intermittent puffi- 
ness of the eyelids (cro talus) may afford an extra indication. The location of 
the eruption, however, is not important in the presence of other marked indica- 
tions for arsenic, and the same may be said as to the kind of lesions, though 
in the author's experience it seldom takes precedence of other drugs for vesicu- 
lar or pustular forms of eczema. 

Psoriasis in its histo-pathology gives better indications for arsenic than in 
its pure symptomatology. The usual lesions of psoriasis may be compared to 
the primary effects of arsenic carried to an extreme, and the history of one of 
my own cases of generalized psoriasis shows that the primary onset of the 
eruption followed the use of over large doses of arsenic prescribed for another 
disease. Most cases lack the other characteristics of this drug. Sometimes 
the lesions will be found very intolerant to the presence of scales which form 
upon them, and to other forms of mechanical irritation. Such intolerance is a 
good indication for arsenic, particularly if some lesions are found upon the face 
and scalp. In the usual absence of the general indications for arsenic in 
psoriasis it is well to remember the suggestion of Hahnemann : " In cases where, 
along with a local affection, the general health seems good, we must proceed 
from the at first small doses to larger ones." It is not necessary, as was once 
believed, to produce and maintain slight toxic effects in order to obtain a cure. 
The second decimal or more often the third decimal is low enough in the attenu- 
ation scale. 



ARSENICUM M.IH'.M 517 

Dermatitis exfoliativa, ;i ran- disease of aduH life, presents cutana 
features similar to those obtained on animala from the administration of u 
as well as a varying likeness to its human pati The fever, malaise 

and impairment of health which may precede or attend the onsd of the die 
the emaciation, the reddish-purple, drj skin, exfoliative whitish-brownish s 
the swelling of the ears, eyelids in marked cases, the occasional alopecia, and 
the suhsequent pigmentation — all bear a resemblance to this drug. 

In some very rare types of inflammation of the skin attended with more or 
less exfoliation of the epidermis, described as dermatitis exfoliativa neona- 
torum, epidemic exfoliative dermatitis and parakeratosis variegata, the 
symptoms given in the few recorded cases indicate that arsenic oughl to he a 
helpful remedy at some stages in their course. In that grave and little under* 
stood affection known as pityriasis rubra, which apparently begins in the .-kin 
and secondarily leads to visceral disorders, arsenic in large doses has repeatedly 
failed to benefit, but the many points of similarity in symptoms give hope that 
it might prove remedial or palliative in minute doses in those cases where 
burning and itching sensations, great intolerance of scratching and rubbing, 
and aggravations from cold are marked features. The gross pathological 
changes in this disease in the epidermis hold a pathological resemblance to the 
known effects of arsenic on the epidermis of animals. 

Lichen ruber, another malady of rare occurrence and persistent gravity, 
manifests a number of symptoms found in the pathogenesis of arsenic. In- 
deed, this drug in full doses is about the only remedy that has been found of 
benefit to patients afflicted with this disorder; while our Materia Medica fur- 
nishes other drugs likely to be indicated and useful in the varied forms of 
lichen ruber; arsenic will probably remain the sheet anchor in the more pro- 
nounced cases. 

The less grave and less rare lichen planus is not likely to show very 
marked indications for arsenic in the early stages, when the seat of morbid 
activity is in the papillae of the corium, but in the later stages marked by in- 
creased changes in the cells of the epidermis arsenic hastens resolution and 
diminishes the tendency to pigmentation, particularly if the general condition 
resembles that produced by the drug. This correspondence is not often ob- 
served, and hence another drug may be better indicated or arsenic must be 
given in low attenuations in order to touch the skin lesions. 

Keratosis pilaris may respond to arsenic when the typical indications are 
present. 

Urticaria, U. pigmentosa. — Occurring in the anaemic or cachectic, tend- 
ing to recur regularly or become chronic: appearing after midnight with rest- 
lessness, stinging, burning sensations, worse from scratching, cold, better from 
warmth. 

Acrodynia, Pellagra. — Arsenic is likely to be indicated in some cases by the 
presence of one 01 more of its prominent characteristics. 

Purpura. — In the asthenic with unusual lassitude and malaise: purpura 
hemorrhagica following periodic fever or attended with febrile exacerbations: 



518 ARSENICUM ALBUM 

in the epidemic form, especially when lesions are situated on neck, trunk and 
thighs. 

Rosacea. — In debilitated or malarial subjects, when aggravations are at- 
tended with burning sensations and affected skin is very intolerant to mild, 
local stimulation. Dirty, rough, dry appearance of contiguous skin. 

Herpes facialis or progenitalis. — When accompanied with intense burn- 
ing, irritated by the slightest friction and occurring periodically may be often 
cured with arsenic. 

Herpes zoster. — Debilitated subjects, preceded by intolerable neuralgic 
pains, anxious restlessness and fear of attack ; pains change into intense burn- 
ing with the development of vesicles, worse at midnight and from cold applica- 
tions, better from warmth. 

Scleroderma. — Early stages when the skin is thickened, dry, scaly, yel- 
lowish, and the general symptoms call for arsenic. 

^Perforating ulcer of the foot, Diabetic gangrene, Hysterical gangrene. — 
The dry gangrenous lesion probably due to local derangement of nutrition 
from peripheral nerve influence will point to arsenic as a remedy when the 
general symptoms in a measure correspond. 

Carbuncle. — Large, swollen, dark red or purplish area burning like fire, 
attended with prostration and anxious restlessness. Symptoms worse after 
midnight. Local sensations worse from cold, better from warm applications. 
After sloughing slow and malignant in course, with bluish areola and bluish 
base. 

Lupus vulgaris. — Ulcerative stage or type, with bluish or violet redness of 
adjacent skin, subject to periodic exacerbation, unusual burning sensations or 
painful sensitiveness, relieved by warmth. Indolent, scaly form, intolerant to 
local stimulation, which causes burning and soreness. Progressive emacia- 
tion, prostration and periodic aggravation of symptoms or conditions. 

Leprosy. — Hypersensitive erythematous patches followed by loss of or less- 
ened sensation and change of color to yellowish brown. Periodic increase in 
number or size of patches. Livid tubercles becoming bronzed, painful on pres- 
sure. Burning sensations in various parts, prostration, restlessness at night. 
General aggravation from cold and amelioration from warmth. 

Erysipelas. — Of face or head attended with oedematous swelling, unen- 
durable, burning, anxious restlessness, frequent thirst, prostration. Aggrava- 
tions from cold, after midnight, relief from warmth. Tendency to vesicular 
or gangrenous changes. 

Epithelioma, Paget's disease, Carcinoma, Sarcoma. — Indurations and 
ulcerations, chronic in course, attended with excessive burning, soreness, and 
unusual sensitiveness after destructive local applications. Emaciation, pros- 
tration, cachexia. Symptoms worse at night. Recurrent or inoperable cases 
may be delayed in course by arsenic. 

The best remedial dose of arsenic can hardly ever be the same in any two 
cases of skin disease. When the general local symptoms and modalities of the 
disease simulate those characteristic of arsenic, it may be administered con- 



ARSENICUM BROMATUM— ARSENICUM HYDROQENISAT1 M 518 

fidently in the higher attenuations (sixth decimal and above) ; Km when the 
surface conditions only call for it, as a rule, lower and lower attenuations must 
be given until a response is noticeable; then sometimes the dose can be les- 
sened a fraction. 

ARSENICUM BROMATUM 

If to the characteristics of arsenicum we add the cutaneous effects of 
"bromism" we obtain a fair conception of the scope of action of this salt on the 
surface tissues. The general symptoms are chiefly those of arsenic, the local 
those of bromine. Papulo-pustular lesions bordered by a deep red areola vary- 
ing in size and depth, slow in onset and course, often "blind" and even after 
spontaneous rupture slow to resolve, extremely sensitive at the periphery and 
sometimes anaesthetic at the centre, with a tendency in persistent cases to form 
compound lesions, and to occasionally ulcerate or pursue a malignant course 
are the principal objective features of the eruption. 

Acne occurring in the cachectic or scrofulous may present good indications 
for the bromide of arsenic. Such cases are usually worse on the hairy parts of 
the skin; the eruption extends beyond the ordinary limits of the disease and 
pursues an indolent course. 

Hydradenitis suppurativa may present pathological and objective simi- 
larity to the effects of bromide of arsenic, and it should be considered in select- 
ing a remedy. 

Rosacea. — In the second stage when the general indications point to 
arsenic and the local approach the conditions described above, especially if the 
papulo-pustular lesions are widely distributed over the face, and the disease is 
aggravated in the spring. 

The third decimal attenuation of bromide of arsenic is a suitable dose for 
most cases. 

ARSENICUM HYDROGENISATUM 

When the symptoms indicate arsenic and are characterized by violence in 
their onset and course, and the lesions early show a purplish or violet tinge of 
color this drug may be considered. 

It gave apparent and prompt relief in the early stage of acute lichen planus 
under the writer's care. Too little is known of its therapeutic scope to speak 
with any certainty of its place in the treatment of skin affections. 



520 ARSENICUM 10 DATUM 



ARSENICUM IODATUM 

Arsenic and iodine produce like symptoms to a limited extent. Together 
they form a superior remedy to either alone in a few affections of the skin. 
This salt gives rise to primary lesions of papules which pass into vesicles or 
more commonly into papulo-pustules. Their evolution is usually attended 
with itching — worse from washing; if the disease has persisted for months, 
cervical or lymphatic glands are found swollen, and in scrofular types the 
enlarged glands may precede eruptive outbreaks. 

Acne occurring in the debilitated or tuberculous, who suffer from cardiac 
weakness and loss of flesh, may be helped with the iodide of arsenic. The 
characteristic lesions are hard shotty papules, sometimes infiltrated at the base, 
andTbecoming pustular at the apex only ; these often develop rapidly, but disap- 
pear slowly if not treated, nearly always feel or look worse from washing or any 
local stimulation and ultimately leave scars. Enlarged glands and nervous 
irritability are further indications for this drug. 

Acne varioliformis has been cured with the iodide of arsenic. The indica- 
tions for it are chiefly objective and pathological. 

Among diathetic affections this salt is especially adapted to forms of 
subacute or chronic eczema dependent on a depraved nutrition, even when the 
appetite and apparent ability to digest food remains. Such eczemas may be 
localized on the hands, face (beard) and genitals, or be more or less generalized 
over the surface. The primary lesions are usually papules or papulo-vesicular, 
and later some may pass into the pustular stage. Their evolution is attended 
with great itching, worse from washing. If the disease has persisted for 
months the cervical or other lymphatic glands are found swollen, and in scro- 
fulous types the enlarged glands may precede the eczematous outbreak. The 
tuberculous eczema or eczemas associated with scrofulodermata, whatever the 
form of lesion, may obtain relief from the action of this drug. 

Lichen scrofulosorum, even when unattended with eczematous symptoms, 
may show at times an intolerance to irritation (scratching), which, together 
with adenopathy and the situation of the papules at the pilo-sebaceous follicles, 
are good indications for the iodide of arsenic. 

Distinctly papular varieties of eczema sometimes described as eczema lich- 
enodes, lichen eczematodes, lichen simplex, which co mm only develop an in- 
tense itching from scratching, with perhaps some oozing from the summits of 
the purplish-red excoriated papules, may be benefited or cured with the ar- 
senicum iod. 

In lichen planus presenting indications for arsenic the author has found 
the iodide serviceable when the former failed to give appreciable benefit. 

Prurigo. — Itching as from flea bites over a wide surface both day and night, 
especially arms and hands, worse from washing : dryness of skin with a ten- 
dency for the excoriated lesions to maturate ; in thin, anaemic' or scrofulous 
children with poor circulation. 



ASTERIAS RUBENS aikum \i i;i \i \iii:i\iim\i 521 

Rosacea. — Second stage in scrofulous subjects with transparent white: 
of unaffected skin and a preponderance of hard papules or small papulo- 
pustules on the bearded portion of the face, burning or itching alter 
washing. 

Sycosis. — Hard, shotty papules on the infiltrated base, becoming pustules, 
some leaving scars. Burning, itching sensations, worse from bathing. En- 
larged lymphatic glands in chronic or scrofulous cases. In debilitated sub- 
jects troubled with cardiac weakness, night sweats, etc. 

Tuberculosis cutis, Lupus vulgaris, Scrofuloderma. — Emaciation, weak 
circulation, nervous irritability. Various lesions tending to first suppurate at 
comparatively small points which extend or multiply and ultimately lease 
scars. Sore burning sensations sometimes aggravated by washing or stimulat- 
ing local treatment. 

Syphilis. — Secondary papulo-pustules which tend to ulcerate freely, at- 
tended with bodily weariness, heaviness of the limbs, general anaemia and swol- 
len lymphatic glands. 

Epithelioma, Paget's disease. — Indurations which ulcerate with compara- 
tive rapidity; burning pains, worse from washing parts; mammary tumor, with 
retracted nipple, becoming sensitive and subject to burning pains; cachectic 
anaemia, cardiac weakness. 

The dose of iodide of arsenic must usually be low, seldom higher than the 
third decimal. 

ASTERIAS RUBENS 

This drug may be considered in the selection of a remedy for psoriasis 
occurring in neurotic subjects with cutaneous lesions predominating on the 
left arm and chest. Such association with neuroses (particularly epilepsy and 
chorea) must be rare, but in a disease so difficult to cure as psoriasis all phases 
of a case must be studied and treated. 

It may also be considered as a remedy for herpes zoster of left breast or 
arm when the neuralgic pain extends from before backwards, especially in 
neurotic subjects who are hysterical and cannot keep quiet. 

It may be given in the sixth decimal. 



AURUM-AURUM MURIATICUM 

The soluble salt of gold meets all the indications for the metal in skin affec- 
tions. This drug' produces a physical and mental depression, resembling, in 
some respects, the syphilitic cachexia or the constitutional effects of mercury, 
with a tendency to structural changes in various tissues. On the skin disorders 
of perspiration, pigmentary, papular, nodular, vesicular and pustular lesion* 
have been noted. The chief sites of disturbance are the inner thighs (sweat). 
face, neck, behind the ears and on the legs. Sensation is not important — burn- 



522 BARYTA CARBONICA, ACETICA, IODATA, MURIATICA 

ing, itching and crawling are most common. Conditions or sensations are 
usually worse at night, in the open air, from walking, and are better after sleep. 

Local hyperidrosis of the inner thighs occurring in the cachectic, melan- 
cholic, or in old age, may be relieved with aurum mur., particularly if the 
modalities correspond. 

Cachectic acne of the face occasionally calls for aurum mur. when there 
are few or no comedones associated with the papules and pustules, the lesions 
are unusually red and more numerous on the nose, are made worse by exercise 
in the open air, by sexual reflexes (flushing of face), and when the subjects are 
melancholy about their diseases. 

Erythema nodosum, erythema induratum. — Elevations on leg and below 
knee, changing to nodosities under the skin ; elevations on legs and calves look- 
ing like blotches from the stinging of nettles, burning, and feeling like knots ; 
of aTdirty yellowish color; wheals under skin on leg; over heel and behind 
knees ; in persons with weak circulation and cardiac oppression, with or without 
cachexia ; with sensations and conditions worse from walking, the open air, and 
better from rest in recumbent position and after sleep. 

Acanthosis nigricans. — Aurum should be studied in cases of this rare dis- 
ease from its influence on pigmentation, etc. 

Tuberculosis cutis, Lupus vulgaris, Scrofuloderma. — Beginning in or 
near the mucous outlets; fetid, purulent or offensive secretion. Deep ulcers 
with sore boring pains, worse at night and when out of doors. Hysterical 
despondency, tremulous weakness, great sensitiveness to cold. 

Leprosy. — Small and large blotches of a dirty yellow color, brownish eleva- 
tions on the nose, lump in groove between nose and cheek ; destructive process 
affecting bones of nose, with offensive discharge. Melancholy but disinclined 
to talk about sickness. 

Syphilis. — Destructive lesions of secondary or tertiary stage, with noc- 
turnal aggravation of pain. Disgust of life, suicidal thoughts, rapid ques- 
tioning without waiting for answer. 

Aurum mur. should rarely be employed above the sixth decimal attenuation. 
Often the third or fourth is more serviceable. 

BARYTA CARBONICA, ACETICA, IODATA, 
MURIATICA 

The barium salts may be useful in skin affections appearing in the scrofu- 
lous or presenting a resemblance to the scrofulous type. The eruptions are apt 
to be indolent in behavior or so-called "unhealthy" in course, becoming pus- 
tular and not responding readily to treatment. The surface tissues lack 
vitality, the oil glands may be affected, the feet or hands sweat excessively, and 
the subject may look prematurely old. In fact, as in the aged, local or general 
stimulation often gives a corresponding though temporarv improvement. 



BARYTA CARHONICA, ACETICA, IODATA, MURIATB \ ■•-■'• 

Hyperidrosis of the feet or hands in scrofulous subjects, obstinate in course, 
worse while at rest in the morning, and relieved by exercise <>ut <rf doors, maj 
be helped with baryta carb. 

Steatoma, or a tendency to the formation of fatty tumors, may (in suita- 
ble subjects) be arrested with baryta carb. 

Acne (simplex or indurata) is likely to be benefited by baryta when the 
lesions continue to appear persistently, associated with comedones, signs of 
scrofula; only sensations of tension are felt in or about the lesions, improvement 
follows from local stimulation (friction, etc.) of the affected skin and aggravo- 
tions follow the use of alcoholic beverages. 

The carbonate is to be preferred, except when the pustules are unusually 
numerous and persistent, then the muriate may be more effective. 

Alopecia prematura in the scrofulous should lead to a study of baryta 
carb. 

In eczema the lesions indicating the barium salts are papulo-vesicular and 
papulo-pustular, either generally distributed or situated on the thighs, hack, 
arms, chest and about the genitals. In young children the eruption may pre- 
dominate on the face, ears or head, and the cervical or occipital glands will 
be found enlarged and not infrequently the tonsils will be found hypertrophied. 
Itching may be absent but is often severe, and is usually worse in the morning, 
on walking, from rest in the daytime and from bathing; it is relieved by 
scratching (sometimes changed into a sore sensation), and all symptoms by 
exercise out of doors. 

The carbonate of barium is usually employed, but when there is well- 
marked mental or physical depression or the lesions are pustular or persistent 
the muriate is to be preferred. 

Lichen scrofulosus, almost an unknown disease in America, ought to be 
favorably influenced by the action of baryta carb. or baryta mur. Possibly the 
iodide of barium might prove the preferable salt. Clinically it has been found 
curative in scrofulous affections of the glands. 

Keratosis senilis may be arrested or mitigated by the internal administra- 
tion of baryta acetica or carbonica when the symptoms indicate one or the 
other of these salts. 

Keratosis palmaris et plantaris, with a history of sweating of the palms 
or soles among the primary symptoms, followed later by a dry, thick parch- 
ment-like condition of the skin on these surfaces and a dry, scaly condition 
of the skin on the dorsal, is likely to be benefited by baryta carb. Mental dull- 
ness and weakness has been observed in some of these cases very like that 
ascribed to this great tissue drug. For the congenital and rarer variety some- 
times associated with naevi on other regions of the surface baryta mur. is the 
better suited. Indeed, what is known of the action of this salt on the central 
nervous system places it in a nearer relationship to symmetrical keratosis. 

Tinea circinata. — Which spreads actively from lack of cutaneous resist- 
ance. Especially in the scrofulous or poorly nourished. 

Tuberculosis verrucosa, Scrofuloderma. — In undeveloped or prematurely 



524 BELLADONNA 

old children or adults. Enlarged glands slowly undergoing softening and 
spreading to other parts. Frequent attacks of tonsilitis or quinsy, great sensi- 
tiveness to cold air, sweating of feet and hands. Burning or pricking sensa- 
tions worse from rest, while thinking of symptoms and mornings, better from 
open air exercise. 

Colloid degeneration of the skin. — This rare affection may call for baryta 
when signs of presenility or scrofula are found, or a history of frequent attacks 
of sore throat after exposure to cold is given, and the skin disease first appeared 
after a series of exposures to the elements. 

Lipoma. — Fatty tumors about the neck or back; in scrofulous or prema- 
turely old subjects, who lack physical or mental energy or are subject to hyperi- 
drosis. 

Verruca. — Bapid development of warts or increase in number in indi- 
viduals with enlarged glands, poor circulation and sensitiveness to cold. 

"The carbonate of barium is most often indicated, especially when the tonsils 
are diseased and the patient appears aged beyond his years. The iodide when 
the patient is of stunted growth, and a large number of different kinds of 
glands (tonsils, lymphatic, testes, prostate, etc.) are affected. 

The barium salts may be given for their effect on the skin in the sixth to 
twelfth decimal attenuation. 



BELLADONNA 

Among the many important effects of belladonna on the human organism 
are hyperemia and hyperesthesia of the skin. These effects are believed to 
arise from the toxic influence of the drug on the nerve centres. In an analo- 
gous way acute congestions and inflammations of the skin originate from the 
poisonous or irritant effects of organic products in excess or abnormally present 
in the system. Aggravations of symptoms occur from touch, draft of air, from 
warm to cold air and from direct heat (sun or fire). If the diffused congestion 
is intense or prolonged enough, the skin, especially of the face, becomes puffed, 
but remains dry and later may desquamate, or in circumscribed patches of 
inflammation necrosis of the tissues may occur. It is chiefly in the early 
stages of cutaneous hyperemias occurring in the plethoric and presenting 
similar symptoms to belladonna that it does its best work. 

Miliaria rubra. — Belladonna is curative when the onset is attended with 
little or no perspiration; the affected skin is very dry, red and sensitive, and 
the patient is excited or stimulated by the cutaneous efflorescence. 

Acne occurring in the plethoric or in those subject to flushing of the face, 
which is slow to subside, with bright red papules and intervening skin of a 
fainter red, accompanied with a fine stinging sensation and sensitiveness to 
touch, worse during menstruation and from any excitement, may be frequently 
relieved in the early stage with belladonna. Barely this is a good remedy- 
when pustules form rapidly, but never in advanced cases. 



BELLADONNA 

Erythema scarlatiniforme, E. multiforme, E. nodosum, E. induratum. — 
Belladonna may bo indicated in the early bypersemic or even later 
any of the forenamed affections by the bright red or Bcarlet hue of the ery- 
thema, sensitiveness to touch, burning, smarting or itching sensations, with 
aggravations from drafts of air and from direct heat. 

Acute or subacute erythematous eczema of the lace occasionally presents 
a striking objective and subjective likeness to the described effects of bella- 
donna on the skin, and then, if given early in the attack, often promptly relieves 
if it does not complete a cure. 

Dermatitis exfoliativa and pityriasis rubra present surface conditions 
and symptoms in their early stages not unlike the effects of belladonna. In 
the former the appearance of diffused patches of livid red shining skin, some- 
times ushered in with fever, the occasional involvement of the mucous mem- 
branes of the naso-pharynx and conjunctiva, the persistent dryness of the skin 
and the final tendency to furunculosis are the chief points of resemblance. In 
the latter rarer and graver disorder its apparent primary origin as a vast 
superficial hypersemia of the skin, circumscribed or diffuse but spreading, 
gives a basis for hope that this drug might prove helpful in cases possible 
to cure. 

The above diseases are apt to appear in the more vigorous periods of life 
and independent of antecedent disorder, and belladonna is most useful for the 
natural active and plethoric individual, and in the active or early stages of 
congestion and inflammation. 

Dermatalgia. — In the plethoric with over-excitability of all the senses; 
pains come and go suddenly leaving parts sensitive to contact, changes of tem- 
perature, drafts. Relief from being wrapped up in a warm room. 

Rosacea. — Frequent intermittent flushing of the face with sensitiveness 
to touch in early stage, in full-blooded, excitable women; especially at the 
menopause, or in the second stage when pustules rapidly form on nose and 
cheeks attended with heat, throbbing and sometimes twitching of the muscles 
of the face. 

Herpes zoster. — Sudden attacks with unwonted redness, heat and extreme 
sensitiveness to contact; pains come and go, worse from warm applications; 
prevesicular stage. 

Furuncle, Carbuncle, Erysipelas. — Early stage when there is extended 
redness, great sensitiveness to touch, painful sensations which come and cease 
suddenly, sensory excitement and fever with cerebral symptoms. Aggrava- 
tions from drafts, touch, changes of temperature and direct heat. Especially 
for boils and carbuncles which develop and suppurate rapidly. 

The lower attenuations of belladonna, first to sixth decimal, are most effect- 
ive in cutaneous diseases. 



526 BENZOIC ACID— BERBERIS 



BENZOIC ACID 

This drug creates disorders in the -system, with symptoms corresponding to 
the uric acid diathesis, and notably an offensive urine variable in quantitative 
and qualitative constituents, therefore sometimes hyperacid and sometimes 
alkaline and variable in color. The change in the skin is usually erythematous 
in nature, with sensations of itching, burning, often aggravated by scratching. 

Erythema intertrigo. — Erythema between the thighs and genitals or other 
opposing surfaces, with pungent acid urine or sweat; in the gouty or rheu- 
matic; with itching sensations changing from place to place and made pleas- 
urable by scratching. 

Acute and subacute eczema due to the rheumatic or gouty diathesis, with 
more-.or less characteristic urinary symptoms, may be greatly benefited by this 
drug. The type of eruption is usually erythematous or finely papular, and 
burning sensations may mingle with itching or follow scratching. 

Infants and young children who have had a poorly selected diet may acquire 
a diathetic state, productive of eczematous eruptions and derangements of the 
secretions calling for benzoic acid, after correction of the diet. More often, 
however, in infants the cutaneous inflammation is caused by contact of the 
abnormal urine, and is in nature a dermatitis rather than an eczema. Here 
the condition of the urine is probably the same, due to the presence of modified 
uric acid, known as 'Tiippuric" acid. The same indications for this drug hold 
good in either case. 

Benzoic acid may be given in the second decimal and higher attenuations. 



BERBERIS 

Berberis, like some other drugs, may be indicated chiefly by symptoms 
found elsewhere than in the skin. The more characteristic are often urinary 
or hepatic in location, but its pains may be more widely distributed and may 
be described as shooting, tearing, sticking, cutting and burning in quality, 
while in the affected skin itching, crawling and bruised sensations are felt. 
Through its action on the vaso-motor system berberis produces a capillary 
venous stasis and a transudation of blood coloring matter into the skin, thus 
staining (mottling) the surface. It also seems capable of exciting inflamma- 
tion of the skin reflexly from organs for which it shows a distinct affinity. 

Acne simplex or indurata. — Berberis is curative in acne due to reflexes 
from hepatic, urinary, hemorrhoidal or menstrual troubles, when the lesions 
begin as hard distinctly red papules with a darker areola; and whether they 
subside by resolution or after suppuration leave brownish pigmentations. The 
pimples are usually sensitive to touch and heat and are temporarily relieved 
by cold applications. 



BORAX 587 

In eczema any farm when the hepatic or urinary symptoms of berb 
are found, this remedy may be given with confidence if tl - curable. 

Eczema of the arms and of the hands are the most characteristic in Location; 
the papulo-pustular form of lesion with an unusual areola and leaving stains 
as resolution begins is the most common type of eruption. Circumscribed pig- 
mentation of the skin following eczematous inflammation is almost a keynote 
for berberis. The local sensations of itching, burning, etc., are made worse 
by scratching, warmth, walking, pressure, and may be temporarily rah 
by cold applications. 

Lichen planus is attended with considerable pigmentation of the skin, 
which becomes more apparent as the primary lesion subsides. When the erup- 
tion occupies its classical situation on the inner surface of the forearms, ber- 
beris is indicated by location and by the sensation which generally attends an 
outbreak of the eruption on the arms. A pathological relationship may also 
exist, as lichen planus is believed to arise primarily from some vaso-motor 
disturbance leading to an engorgement of the superficial capillaries of the 
skin. The presence of urinary or hepatic symptoms in a case of lichen would 
likely give the remedy greater curative value. 

Purpura, Peliosis rheumatica. — Dusky red petechial spots on arms, fore 
part of shoulders, feeling like a bruise when grasped; vibices near external 
condyle of elbow : rheumatic lameness, stiffness and bruised sensations in back 
and extremities, or shooting pains in region of kidneys with urinary symptoms. 

Urticaria pigmentosa. — From hepatic, urinary and gastro-intestinal re- 
flexes ; dusky color in centre of lesions, with shooting, sticking, burning, bruised 
or rheumatic sensations. 

Berberis acts best in the low attenuations, and often the tincture is re- 
quired to produce the best effect. 



BORAX 

Biborate of soda acts on the tissues of the mucous membrane, the skin and 
its hairy appendage, and produces a general nervous sensitiveness which finds 
its greatest emphasis in the shrinking from downward motion of any kind. A 
natural aversion to going down a steep flight of stairs, to walking or driving 
down hill, etc., may be taken as a good indication for this drug. On the hair 
it produces a characteristic effect, causing the end to turn on itself and become 
tangled, and it may cause inflammation of the hair follicles. The skin lesions 
are not very characteristic, but resemble forms of superficial congestion or 
inflammation, accompanied with itching, stinging, crawling, burning and 
tensive sensations. These are worse from pressure and are relieved somewhat 
in the open air. 

Acne. — Papular acne of the cheeks or chin associated with inflammation 
of the mouth or naso-pharynx or with the peculiar nervous symptoms of borax- 
may be cured by its action. 



528 BOVISTA 

Distichiasis. — Whether acquired or associated with inflammation of the 
muco-cutaneous surface of the lids, indicates borax even when other charac- 
teristic symptoms are lacking. 

Plica polonica, Neuropathic plica. — Objectively borax is indicated in 
plica polonica, though causal treatment is most indicated. In the rare neu- 
rotic plica, borax ought to be especially curative. 

Erythema caloricum (chilblains). — Eed spots on the face, toes, feet, legs 
or fingers, with itching as from freezing, or crawling sensation, relieved in the 
open air. 

Erythema traumaticum. — Persistent redness of the skin from slight in- 
juries, with itching or stinging sensations; better out of doors; erysipelas-like 
redness (erysipeloid) of face, leg or foot, with tension and burning, worse 
from pressure. 

Trade eruptions. — Eedness and soreness on the back of fingers, joints and 
hands, with intense itching, biting and stinging sensations and an irresistible 
desire to scratch them violently ; in grocers, bakers, butchers, etc. 

Psoriasis and pityriasis rosea in some forms may resemble the mild der- 
matitis caused by borax, but these dermatoses are not often associated with the 
aphthous type of inflammation of the mucous membranes or the peculiar nerv- 
ous symptoms of borax. A natural aversion to going down a steep flight of 
stairs, to walking or driving down hill, etc., may be taken as a good indication 
for this drug. Lesions of the mucous membrane and psoriatic patches indicat- 
ing borax have no tendency to heal and bleed easily on artificial irritation, but 
aside from this not unusual feature and the peculiar nervous characteristic of 
borax we have no reliable indications for its use in surface diseases. On the 
hair it produces a characteristic effect, causing the end to turn on itself and 
become tangled. 

Only the lowest attenuations have proved beneficial in the author's ex- 
perience. 

BOVISTA 

This fungus, acting on the peripheral blood-vessels, causes circumscribed 
forms of inflammation of the skin in the shape of papules, vesicles and pustules. 
The eruption is attended with persistent itching which is worse in the morn- 
ing, from general warmth (in hot weather), from washing and is not relieved 
by scratching; hence the affected part may be torn or rubbed until it is raw 
and oozing, in the vain effort to get relief. This artificial irritation leads to 
the formation of abundant crusts not to be ascribed to the drug. The uncov- 
ered parts of the skin are points of selection, or the common sites of vesico- 
pustular eczema in children. Three general indications for bovista are heavi- 
ness and fullness in the head, irritable sensitiveness to almost everything, and 
motor weakness and unsteadiness simulating awkwardness. 

Acne. — Acne of the face, worse in the' slimmer, occurring in sensitive, 



BRYONIA 528 

awkward boys or girls, may be frequently cured with bovista. Jt is also a good 
remedy for acnoid eruptions due to overuse of cosmetic powders or past 

Trade eruptions. — Erythematous or papular eruptions on the bands or 
arms, due to occupations (grocers, bakers, masons, etc.), attended with itching 
and soreness, worse in warm weather and from washing, not relieved by 
scratching; in irritable, sensitive persons with fullness in the head and mus- 
cular unsteadiness. 

Eczema of the ears, face and scalp, occurring in infants and children, 
which are or have been scratched or rubbed persistently at every opportunity, 
particularly in the morning on waking or after washing, and on which thick 
crusts form when permitted to do so, will nearly always respond to the action 
of this remedy. If the child is at the same time sensitive, irritable or awkward, 
the response is likely to be more prompt. 

In adults the eczematous lesions calling for bovista are usually distinctly 
red papules or papulo-vesicles, and located on the back of the hands or fore- 
arms. These are sometimes classed as " occupation eczemas," that is, eczema 
essentially due to the eczematous diathesis, but excited by frequent contact 
with foreign substances, as in the occupation of bakers, grocers, etc. Rarely a 
similar form of eruption is seen on the feet and legs, not excited by externally 
acting agents, but presenting like indications (above noted) for bovista. 

Pruritus, P. ani. — General or local itching, worse from warmth, mornings, 
washings, from scratching, or the latter changes the sensation to burning; 
especially adapted to pruritus of anal region and of feet and legs. 

Urticaria. — On waking in the morning, in warm weather, with persistent 
itching, worse from bathing, not relieved by scratching. 

Acrodynia, Pellagra. — Some general and local symptoms of those affec- 
tions correspond to those produced by bovista. 

Medium attenuations, third to sixth decimal, are most reliable. 



BRYONIA 

The general action of this valuable remedy needs no mention here. Ex- 
cluding the exanthemata it occupies a small place in the dermatological thera- 
peutics, and then there probably exists an underlying rheumatic or analogous 
diathesis which affects the fibro-muscular structures of the skin and subcuta- 
neous tissue. The fibro-muscular tissue of the skin is called into action by 
changes in external temperature, and we find the time aggravations of brvonia 
correspond with the morning and evening variations of temperature, and, that 
while the drug is indicated for eruptions appearing in warm weather, local 
relief is sometimes obtained from artificial warmth. The perspiratory function 
is often deranged — suppressed or stimulated under different states. The sur- 
face lesions are more often small, closely situated papules rather widely dis- 
tributed, occasionally becoming minutely vesicular, or the eruption may be fine 
enough to constitute a rash, but is never a distinct erythema. 



530 BRYONIA 



Miliaria and miliaria rubra. — This warm weather affection often calls for 
bryonia from the presence of a fine papular, papulo-vesicular or a clear vesicu- 
lar eruption (either due to suppression of or too abundant perspiration), men- 
tal irritability, aggravation from exercise, etc. 

Seborrhceic dermatitis. — The adaptability of bryonia to hot weather affec- 
tions is occasionally shown in cases of dermatitis, apparently due to excessive 
and oily transpiration (the sebaceous and sweat glands both seem to participate 
in the increased action). Biting, burning, itching, and other sensations are 
usually pronounced in such cases, and are always worse from walking, scratch- 
ing, sweating and toward night; and are better from rest, particularly in a 
horizontal position, and sometimes from warmth. 

In children an eczema is occasionally seen which begins in warm weather, 
and presents symptoms similar to those credited to bryonia. The eruption 
rhay be quite general over the neck and trunk, less or not at all on the extremi- 
ties. In the beginning the efflorescence may resemble miliaria rubra, but the 
symptoms and course are clearly eczematous. The author has seen such cases 
quickly respond to the influence of this drug. 

On the deeper structures of the skin and subcutaneous tissue bryonia may 
imitate a hypertrophy of the connective tissue (with or without oedema) akin 
to the changes which occur in two rare diseases known as sclerema neona- 
torum and oedema neonatorum. 

Urticaria. — In warm weather, generalized, appearing after sweating or 
subsequent to suppression of sweat; itching relieved by full efflorescence of 
eruption, local warmth and pressure; icorse from motion and standing; associ- 
ated with rheumatic pains and mental irritability. 

Purpura, Peliosis rheumatica. — In warm weather following a cold spell; 
aching and weariness in all the limbs, worse from motion, better from rest, 
warmth and hard pressure ; on extremities, especially about knees. 

Scleroderma. — Symmetrical wherever situated, with swelling, tension, 
drawing, stitching, weakness, tearing or stiffness of parts, worse from motion, 
better from warm wraps; associated with easy or profuse perspirations and 
mental irritability. 

Hughes says bryonia has long enjo} r ed a popular repute in the scleroderma 
of horned cattle, and that Dr. Mayshofer proved it on three oxen, in each 
producing the primitive symptoms of the disease. I have myself found it bene- 
ficial in scleroderma of adults, though it is far less often indicated than rhus 
tox. 

Bryonia is administered in a wide range of dilution from the tincture up- 
wards. Probably in cutaneous affections the first to twelfth decimal is wide 
enough, and for marked changes in the subcutaneous tissues it must be given 
in the lowest and possibly at times in the tincture. 



BUFO CADMIUM SULFl RATUM 581 



BUFO 

While the action of this medicine is no! clear, its effects on the aervous 
system and the skin point to its value in rare conditions of the latter due to 
nerve disturbance and characterized chiefly by vesicular and bullous lesions, 
located on soles, palms, fingers, hands and feet, filled with yellowish excoriating 

fluid. The lesions may rupture, reach a large size, exfoliate and leave raw or 
smooth, reddish-hrown spots. Sensations of itching, tin g lin g or burning may 
precede or attend the outbreak. 

Pompholyx. — In neurasthenics, depressed or epileptoid subjects; attended 
with itching or burning sensations, worse from friction of clothing or light 
contact; especially by symmetrical eruption limited to some portions of bands 
or feet. 

Pemphigus. — Preceded or attended with febrile or nervous disturbance: in 
neurotic girls with menstrual irregularities: when eruption is limited chiefly 
to hands, feet, ankles, legs or arms, with pruritic sensations. 

Pemphigus foliaceus.— Yellowish bulla? which soon rupture and discharge 
an excoriating fluid, leaving more or less exposed a red, purplish, raw surface 
exuding ill-conditioned fluid: attempts at repair show in spots of thin, slimy 
skin, with sensations of burning and soreness. 

Bufo may be given in the sixth decimal attenuation. 



CADMIUM SULFURATUM 

Little is known regarding the mode of action of this drug, but it may be 
inferred from its meagre symptomatology that it acts primarily on the blood 
and induces circumscribed hyperemia, transudations of blood coloring matter, 
and sometimes hemorrhages. On the skin it may cause the appearance of ery- 
thematous or pigmentary macular and vesicular lesions; almost exclusively 
located on the face or extremities. Sensations of crawling, itching or numb- 
ness may be felt, but are not pronounced and may be absent. Conditions 
or symptoms may be worse from drafts of air, open air, in sunshine, from stim- 
ulants, grief and vexation, and relieved by eating and rest. 

Chloasma. — Yellowish stains on nose and cheeks, brown on chest and arms. 
worse after exposure to sunshine or wind and from depressing emotions. 

Erythema caloricum (chilblains). — Bluish redness of the skin: erysipela- 
tous redness of the nose with crawling sensations or with itching when touched ; 
from cold, and relieved by scratching, which may excite a pleasurable sensation. 

Cadmium acts well in suitable cases of cutaneous disease in the third deci- 
mal attenuation. 



i 



532 CALADIUM— CALCIUM SALTS 



CALADIUM 



This substance acts prominently on the entire mucous membrane (mark- 
edly on the alimentary tract) and on the skin. It excites in both regions 
characteristic sensations, and is more valuable as a remedy in cases involving 
both structures. 

Pruritus vulvae, P. vaginae. — In all primary cases, especially when reflex 
from the alimentary canal or toxins of indigestion ; itching in small spots and 
usually worse in late afternoon, before midnight, while driving, better from 
walking. 

Urticaria. — On chest associated or alternating with asthmatic breathing; 
jefjex from gastric irritation, with eructations of gas; sensation as if stomach 
were full of dry food, dryness of mouth and thirst with aversion to cold water, 
fluttering in abdomen as of a bird, with nausea ; with sudden itching or burn- 
ing in small spots, worse before midnight. 

Rosacea. — Nose and forehead, at first in small spots, worse after eating, 
sleeping in daytime ; crawling sensations ; especially when due to or aggravated 
by gastric symptoms characteristic of caladium. 

The third decimal is suitable for use in cutaneous diseases. 



CALCIUM SALTS 

Lime is a normal constituent of nearly every solid and liquid of the animal 
organism, and these salts are classed by some with other elements found in the 
system and possessing medicinal powers as "nutrition" remedies. There is 
abundant evidence also to indicate that the disturbances produced by these salts 
are largely by the assimilative processes and correspond to conditions found in 
scrofular, tubercular, and in a greater or less degree to other general or local 
derangements of nutrition. Such disturbances may go on to produce various 
forms of inflammation. Whether the action of these preparations is purely 
nutritive or not is an open question of minor importance in view of their well- 
known remedial virtues. There is abundant evidence, however, to indicate 
that the disturbances produced are largely through the assimilation process, 
and correspond to conditions found in scrofula, tuberculosis, and in a greater 
or less degree to other general or local derangements of nutrition. Studied 
from this basis, the lime preparations may be indicated at times in a large 
number of cutaneous affections. The carbonate, fluoride, phosphate and sul- 
phate have been verified in a number of diseases classed as diathetic. 






CALCAREA ACETTCA CALCAREA CARBONICA 



CALCAREA ACETICA 

This salt is influenced by the acetic acid component, and besides inducing 
a general cachectic anaemia, it shows an affinity for the mucous membranes and 
causes redness and desquamation of the skin. 

Seborrhceic dermatitis of the vermilion surface of the lips may be cured 
with calcarea acetica when other indications correspond, especially when the 
lips are very dry before cracks form, and an itching, crawling sensation is hit, 
obliging the patient to repeatedly moisten them with the tongue. 



CALCAREA CARBONICA 

This drug suits best those who are fair of skin, over fat, large of abdomen, 
perspire freely, are sensitive to cold and are easily fatigued. 

Seborrhceic dermatitis of lips. — This salt is indicated when the upper lip 
is chiefly affected, swollen, cracked, and the features and conditions indicate 
the scrofulous constitution. 

Alopecia prematura. — When loss of hair occurs in fat subjects from lack 
of nutrition, from disease or constitutional weakness, and has been preceded 
by excessive sweating of the head or by eczema or seborrhcea of short duration, 
cal. carb. will sometimes help to renew the growth in subjects below middle 
life. 

When an eczema is engrafted on this constitutional type, possessing only 
a moderate resistance to disease, it is usually of the vesicular or pustular form, 
producing thick crusts, offensive to sight and sometimes to smell, on the re- 
lease of sero-pus beneath. In chronic cases fissures are apt to form and become 
the seat of a purulent exudation, or the disease may assume the squamous type. 
Itching, burning or sticking sensations are worse morning and night, from 
washing, from cold; and are better from indoor warmth. The exposed por- 
tions of the skin, such as the hands, face and ears, are favorite sites of the erup- 
tions. Most cases occur in infancy and childhood, and enlarged cervical glands 
are a frequent concomitant feature. Occasionally in adult life the characteris- 
tic weeping and crusting lesions are found on or behind the ears, and rarely a 
more generalized papulo-pustular eruption calls for this drug. 

Lichen scrofulosus probably exhibits good indications for calcarea carb. 
in some cases. Keratosis pilaris occurring in scrofulous children has been 
greatly relieved bv the persistent administration of this remedy. 

Urticaria. — Whitish wheals which itch intolerably: elevated stripes over 
tibia; always disappear in cool air; when general conditions call for the drug; 
chronic cases. 

Naevus pigmentosum, Verruca. — When apparently due to constitutional 



534 CALCAREA FLUORATA 

conditions; fair, over fat children, sensitive to cold, perspire from slight exer- 
tions and easily tire. Especially when lesions tend to increase in size or 
multiply. 

Clavus. — Associated with cold moist feet and systemic indications for 
calcarea carb. 

Acromegaly, Myxoedema. — Calcarea carb. might be indicated in these 
rare affections by weariness on exertion, sensitiveness to cold, easy perspirations, 
a history of scrofula or evidences of calcareous degenerations. 

Mycosis fungoides. — In cases beginning with urticarial lesions, changing 
to warty growths, with simultaneous swelling of the lymphatic glands. Great 
sensitiveness to cold, perspirations from slight effort, cachectic debility, etc. 



^ CALCAREA FLUORATA 

This salt is adapted to secondary forms of skin disease or to secondary 
changes in the dermal tissues. According to Schussler's biochemic theory, it 
acts on the fibro-elastic tissue of the blood-vessels, lymphatics and the skin. 
When these fibres are relaxed dilatation of the vessels occurs, the connective 
tissue loses its normal resistance and infiltration and induration of the part 
may follow. 

In eczema, due to venous hyperemia, located especially on the legs, worse 
in damp weather, from standing or walking (hence in daytime), and better 
from the recumbent position (hence at night) cal. fluor. is often a serviceable 
remedy. Chronic squamous forms of eczema attended with thickening and 
cracking of the skin, and an apparent loss of all tendency to resolution in the 
diseased parts, even after the underlying diathesis has been controlled, may 
quickly improve under the action of this drug. While the palms and soles are 
the parts for which this remedy has the greatest clinical affinity in the existence 
of squamous conditions, it may prove beneficial whatever the location. For 
eczema of the anus consequent to hemorrhoids and exhibiting a thick, relaxed 
or redundant state of the affected skin, deeply folded on itself and sometimes 
simulating fissures, cal. fluor. is very often indicated. Occasionally the above 
forms of eczema may be seen in scrofulous subjects, rarely a very hard swelling 
of the lymphatic glands may be observed, but, as a rule, this salt does not appear 
indicated for the scrofulous proclivity nearly so often as cal. carb. 

Psoriasis of the extremities, uncommonly hyperaemic, of a deep reddish 
tint and presenting some of the modalities of cal. fluor., may be improved by 
the administration of this salt. 

Keratosis palmaris et plantaris, which probably originates from a moder- 
ate vascular stasis if not capillary varices in the most superfinal vessels of the 
skin, may present symptomatic indications for calcarea fluor., such as aggrava- 
tions from damp weather and the standing position. It has been verified in 
this infrequent disease enough to show its therapeutic power. 



CALCAREA PH08PH0RICA 

In the management of ichthyosis simplex and hystrix calcarea flnor. ifl 
worthy of study. While the disease is probably a deformity of congenita] 
origin, and there are no reliable data to encourage the use of the drug, there 
are pathological grounds for prescribing it, and it is not impossible that ft 
employed at an early stage good effects might be obtained. 

Actinomycosis of the legs with characteristic aggravations responded to 
this remedy. 

Cicatrix, Keloid, Fibroma, Neuroma, Xanthoma, Myoma, Angioma, 
Angiokeratoma, Telangiectasis. — Calcarea fiuorata may be indicated in the 
forenamed affections on pathological grounds, or symptomatically by tin- 
presence of dilated capillaries, hyperemia, aggravation of associated symptoms 
in wet weather, general relief on lying down, and locally from friction. Espe- 
cially suited to persons of weak constitutions and to middle life. 



CALCAREA PHOSPHORICA 

This is one of the tissue remedies particularly adapted to affections occur- 
ring in the extremes of life, youth and old age. In youth it is the anaemic, and 
less often the anaemic from too rapid growth, that calls for this salt. In old 
age defective regeneration of tissue is apparent either too early, suddenly or 
in special directions. Modalities of cal. phos. are very like those of the fluoride. 
The relief of most symptoms from taking the recumbent position is even more 
marked than characterizes the latter. While the phosphate is closely allied to 
the carbonate of lime, it is distinguished by leanness, rather than by over 
plumpness, and a sallow or dirty white complexion of the brunette type rather 
than the fair skin of the blonde type, suggestive of the carbonate. The exist- 
ence of a non-specific cachexia as the probable perpetuating cause of a skin 
eruption may be counted as a good indication for cal. phos. 

Acne simplex. — In thin anaemic boys or girls, at puberty, who have grown 
rapidly, or who suffer from headaches after close mental application. The 
lesions may be few or many, have little or no areola and the contents of the 
pustules are whitish rather than yellow. 

Fragilitas crinium. — Where there has been a history of headaches and the 
state of innutrition resembles the effects of this drug. 

Alopecia prematura, A. areata. — In thin young women especially, when 
there is an absence of any local cause, nutrition is poor, headache frequent, and 
most symptoms are relieved by rest in the recumbent position. 

Lentigo. — Persistent in the young, with a tendency to become worse each 
year; in the thin, anaemic, cachectic or too rapidly growing subject; with head- 
ache relieved by lying down and by mental rest. 

Chloasma. — In the recurrent type, appearing in the same places before 
affected; in the thin, cachectic, or prematurely old: with otbor symptoms 
relieved by lying down. 



536 CALCAREA SULPHURICA 

Cachectic eczema in young people with papulo-pustular, vesico-pustular or 
crusting lesions, usually located on the face, ears, scalp, hands or wrists, may 
find this drug surprisingly curative. Itching' may be intense or slight, but it 
is worse from changes of weather, especially to cold or wet, and often gives 
little or no trouble at night. 

Keratosis senilis and pruritus senilis are two affections of age likely to 
be mitigated by the use of calcarea phos. The latter disease will be considered 
in another class. In keratosis senilis this remedy is indicated by changes in 
the color of the skin — to a waxy, coppery, or greenish hue; by a dry, harsh 
wrinkled or greasy condition of the surface; by eruptions (few or many) 
having the appearance of small exudations in or on the skin. If the subject 
has a gouty or scrofulous history calcarea phos. is all the more indicated. Such 
patients are very sensitive to atmospheric changes, especially to cold, and the 
skin itself is often cool to touch. 

'"Pruritus senilis. — Itching, stinging, biting or formication of various parts 
of the skin; in the anaemic with many wrinkles, dryness and coolness of the 
surface; worse from cold, changes of weather, getting wet, often relieved by 
lying down. 

Prurigo. — Early stage in anaemic, thin children; skin dry and cold; itch- 
ing, worse from cold and wet. 

Rosacea. — In early stages in chlorotic females, who seem prematurely aged ; 
coolness of the surface ; general symptoms relieved by the recumbent position. 

Tuberculosis cutis, Lupus vulgaris, Scrofuloderma. — Thin, anaemic sub- 
jects of the brunette type, with lack of cutaneous resistance to the local spread 
of the disease. Especially valuable in youth or in advanced life. Symptoms 
generally worse from weather changes, cold, wet, motion; often better from 
lying down. 

Leprosy. — Dark brownish spots on the skin, in scrofulous anaemic subjects, 
who feel better in the recumbent position. 

Lymphangioma. — When beginning in infancy and probably due to em- 
bryonic defects. 

Rhinoscleroma. — Calcarea phos. may be indicated in this rare disease oc- 
curring in a scrofulous anaemic subject, with stopping of the nostrils, hard 
swelling of the upper lip, painful on pressure. 



CALCAREA SULPHURICA 

A distinct and persistent tendency for eruptions to suppurate and discharge 
is the chief indication for this salt when other calcarea symptoms are present. 
Aggravations from contact with water is the most important modality. 

Hydradenitis suppurativa. — When the nutrition is poor and there are 
other calcarea symptoms, this drug will sometimes cut short the chronic course 
of the disease. 



CANNABIS I Mm \ 

Acne.— In calcareous subjects when pus points quicklj form at the apex of 

most of the lesions on the face, and the eruption Looks or feels worse from bath- 
ing the parts, calcarea sulph. may be prescribed. 

Dermatitis papillaris capillitii. — lu the: early stages this drug ought to 
prove helpful in cases presenting calcarea symptoms. 

Conglomerate suppurative perifolliculitis.— In a case of this rare affec- 
tion calcarea sulph. should be compared in selecting a remedy. 

Eczema capitis in infants and young children with abundant purulent 
exudation and yellowish crusts nmi BUggest this drug. Pustular eczema about 
both cars occurring at any age may present indication for this remedy. la 
eczema of the beard, often beginning with or complicated by a pustular folli- 
culitis, it is occasionally curative. These are the selective areas for calcarea 
sulph., but the distinct type of suppurating eczema, whenever found in associa- 
tion with calcarea symptoms, may prove amenable to its action. 

Scabies. — Many pustular lesions slow to heal, yellowish crusts, worse from 
working or washing in water. 

Furuncle, Carbuncle, Impetigo contagiosa, Lupus vulgaris, Scrofulo- 
derma. — Later stage with abundant and persistent suppuration and without 
any apparent tendency of lesions to heal. Local or general symptom- worse 
from bathing. 

The calcarea salts may be employed in the sixth decimal attenuation and 
upwards. The carbonate seems to exert its power in a very high attenuation : 
probably, however, this salt does as good work in the twelfth decimal as in a 
higher preparation. 

CANNABIS INDICA 

This drug acts purely on the nerve centres and nerves, often causing mental 
exaltation, disorders of sensation and secondary motor disturbances. In the 
skin it excites sensations of itching, tingling, stinging, thrilling, crawling and 
tension without eruptions, which may be aggravated by touch and relieved by 
scratching. 

Pruritus. — Itching of feet, legs, scalp, face or rarely of other parts, re- 
lieved by scratching; in neurotic subjects who are unduly mirthful or loqua- 
cious, absent-minded or very imaginative. Pruritus ani with sensation of a 
ball in rectum or at anus. Pruritus of scalp with opening and shutting sen- 
sation, crawling and tension. Pruritus from unemia, following auxiliary 
measures of treatment. 

Scleroderma. — Of the legs with sensations in the knees as if clasped by 
birds' claws; stiffness, aching, drawing, paralyzed feelings preventing walking 
upstairs; stumbling, unsteady gait, especially when associated with other char- 
acteristic neurotic symptoms. 

The second or third decimal attenuation is generally most efficient in skin 
diseases. 



538 CANTHARIS 



CANTHARIS 

The effect of cantharides by local contact, and in a less degree by elective 
affinity, on the mucous membrane and skin is that of an irritant poison exciting 
a catarrhal or more profound type of inflammation. The most common sensa- 
tions produced are burning, biting, smarting, rawness, itching, sticking and 
crawling. These are usually aggravated by warmth, touch, pressure, scratch- 
ing and at night. Temporary relief is generally experienced from cold or cold 
applications. 

Erythema caloricum, Dermatitis calorica (burns), D. venenata. — In 

cases attended with burning, smarting, rawness or sticking sensations, worse 
from warmth, pressure, and at night, and tetter from cold or cold application. 
External applications of the second decimal dilution further diluted with water 
sometimes afford prompt relief. 

Acute vesicular eczema of the face or hands attended with burning pains, 
or itching and smarting sensation at the same time, with similar modalities to 
those above named, call for the administration of cantharis. It often affords 
prompt relief of the more painful sensation, but it rarely completes a cure 
alone. Arsenic, rhus or some other complementary drug may need to follow 
it. The presence of the characteristic urinary symptoms of cantharis, in 
eczema about the genitals, is a sufficient reason for selecting this drug. Occa- 
sionally an acute eczema of the scrotum appears to arise with or from exces- 
sive perspiration in the genital region. Such outbreaks are usually attended 
with burning, sticking or itching, and are helped by cantharides. External 
applications of 2x dilution sometimes give prompt relief. 

Seldom are the lesions of psoriasis paresthetic to a degree to indicate 
cantharis. Yet they have been observed covered with scant scales, burning and 
itching at times, especially worse from warmth, scratching and pressure. Then 
this remedy is worthy of trial and has been found beneficial. 

Pruritus vaginae, P. perinei. — When associated with affections of the 
mucous membranes with characteristic sensations, worse from warmth and 
better from cold applications. 

Herpes. — Of face or genitals when accompanied with unusual burning, bit- 
ing, itching sensations ; or associated with gonorrhoea or other urethral inflam- 
mation calling for cantharis. 

Herpes zoster. — Principally after neuralgic stage when vesicles have 
formed and sting, burn or smart, worse from touch, pressure, warmth and at 
night, better from cold applications. 

Pemphigus may be cured with this drug when sensations and modalities 
correspond. 

Erysipelas. — Of the face, with raw, burning, smarting or stinging sensa- 
tions, worse from warmth, better from cold applications. Especially with early 
appearance of vesicles and associated with characteristic urinary symptoms. 



CARBO ANIMALIS— CARBO \ l.< .1 l vmi.is 

Cantharis should be given in the Becond or third decimal attenuations; fre- 
quently the second dilution may be applied locally with comfort to the patient 



CARBO ANIMALIS 

Animal charcoal disturbs tissue nutrition, weakens the digestion and other 
functions and causes local congestions without heat, and winch may induce 
consecutive inflammation of the glandular or other structures. In the skin it 
may give rise to passive erythema with or without papular and pustular lesions. 
These are located chiefly on the face, hands, wrists and feet. Sensations of 
burning, tearing, tension, stinging, itching, coldness or of suppuration may be 
felt. Symptoms are usually worse from cold, from warmth of bed, from 
scratching, and are relieved by rubbing. General indications for this drug are 
sadness, weakness, desire for solitude, heaviness and confusion of the head, and 
a scrofulous or venous type of constitution. 

Erythema caloricum (chilblains). — Dark red spots on cheeks, nose and 
fingers or wrists, without heat to touch; with burning, tearing, stinging, etc. 
Sensations relieved by rubbing, worse in the evening, in bed. from cold; in the 
scrofulous, with enlarged glands, prominent veins, cold and bluish extremities. 

Rosacea. — Well developed cases in middle or later life with sluggish circu- 
lation and distended veins ; coppery redness of cheeks and tip of nose, papulo- 
pustules with yellowish tips on forehead, cheeks and chin ; with morning nose 
bleed; associated with indigestion, nausea, heartburn and tasting of food 
eaten a long time previous. 

Syphilis (Secondary). — Coppery macules on face, with swollen glands, 
sometimes bluish hue of skin, distended veins; prostration with sense of c< in- 
fusion. Loss of hair. 

Carcinoma cutis. — Bluish nodular growths with burning, stinging pains 
relieved by rubbing parts, worse at night in bed, from cold. Especially in old 
people with enlarged veins, who are sad and prefer solitude. 

Verruca. — On the hands or face of old people, with bluish color of extremi- 
ties and occasional pruritic sensations, quickly relieved by friction. 

The medicinal virtues of animal charcoal are largely developed by tritura- 
tion, hence it should be given in powder or tablet form in the sixth decimal or 
higher attenuation. 

CARBO VEGETABILIS 

Vegetable charcoal alters the secretions of the digestive organs, deranges 
digestion, devitalizes the blood, and secondarily lowers nerve function to a 
degree simulating low types of disease. On the skin it may cause the appear- 
ance of macules, papules, vesicles, pustules, alterations in the venous capillaries, 
attended with unhealthy exudations, hemorrhagic complications, a tendency 



540 CARBOLIC ACID 

to persist or change to low forms of inflammation, with burning sensations 
(even in the unchanged skin), worse at night. But it is chiefly in cutaneous 
affections associated with other conditions calling for carbo veg. that it acts 
best. Desire to be fanned is a general keynote. 

Purpura hemorrhagica. — Occurring in the latter part of life, in the de- 
bilitated with offensive secretions, varicose veins, lack of warmth of the surface ; 
following mental anxiety in the nervously weak; recurrent forms with bleed- 
ing from the nose, rectum or genito-urinary tract. 

Rosacea. — Advanced stage with varicose capillaries on the nose ; associated 
with flatulent indigestion from the simplest food; burning sensations in af- 
fected or neighboring skin ; in the debilitated or neurasthenic and generally in 
middle or later life. 

Herpes progenitalis. — Eecurring type following fluctuations downwards 
of debility, dyspepsia or other chronic affections of the mucous membrane with 
mental anxiety; with varicosis of external genitals; burning, itching or sore 
sensations and offensive secretions. 

Carbuncle. — Ulcerative stage or gangrenous appearance, with burning 
pains worse at night, coldness of the extremities ; debility and faint-like weak- 
ness, especially on exertion. 

Lymphangioma, Lymphangiectasis. — Associated with dilated capillaries 
or originating from ulcers ; discharges of lymph and blood. Especially in per- 
sons of low vitality, with disorders of the venous circulation. 

The sixth decimal is the best single attenuation. 



CARBOLIC ACID 

This acid is not only an irritant poison to the tissues, but seems to deprive 
the protoplasmic elements of the power of regeneration of tissue in the affected 
part. It exerts a paralyzing effect on the nerve centres, permitting a prolonged 
dilatation of the blood-vessels, especially of the head and face. Hence the type 
of cutaneous disease to which it is adapted is attended with great redness, a 
marked tendency to persist, to extend or to destroy tissue, even when under 
treatment. The sensations produced in the cutaneous sphere are smarting, 
burning (heat), itching, biting, pricking or crawling, and if the congestion 
become passive in nature, there may be sensations of coldness (or cool to touch 
— rosacea) and rarely of horripilation. Prostration may be a general symptom. 
Aggravations occur at night, from touch and rubbing. Scratching gives some 
relief, especially if the lesions bleed, as they are apt to do if excoriated. 

Eczema of the face, neck or scalp; papular; papulo-vesicular or papulo- 
pustular, but always presenting a marked redness of the surface, which extends 
beyond the other lesions, if attended with fullness in the head, headache or 
constriction of the forehead and temples (indicating fullness of the blood- 



CAUSTICUM 5 » 1 

vessels) m;iy be greatly benefited by the action of this drug. Eczema 0/ the 
dorsal surface of the hands, fingers and between the fingers, with some of the 
lesions above named, sensations and modalities like those of carbolic acid, 

quickly respond to the curative action of this remedy. In such cases the redness 
may be bright, in others dark, as the vascular dilatation is arterial or venous. 

Like the preceding drug, carbolic acid may be occasionally useful in 
psoriasis. It may be indicated when the lesions are intensely aypersmic, 
slightly scaly, bleed easily from rubbing or other artificial irritation. While 
the correspondence, from lack of sensations in most cases of psoriasis, cannol 
be complete, its curative action has been verified in several cases of the disease. 

Theoretically, carbolic acid ought to be beneficial in that rare affection 
described as dermatitis repens. 

Rosacea. — In early stage when redness (with heat) is intense and pro- 
longed, but alternates with pallor; of the dissipated who are subject to periodic 
gastric disorders. In later stages when color is dark red or bluish, sharply 
in contrast with pale skin, cool to touch ; pustules on middle third of nose ; color 
greatly increased by friction, which causes a burning pain. 

Dermatitis herpetiformis, Impetigo herpetiformis, Herpes gestationis. — 
These rare affections exhibit symptoms which correspond in some important 
particulars with the pathogenesis of carbolic arid; vesicles all over the body; 
itching and burning sensations; great tendency to persist, extend and some- 
times become pustular; evident absence of regenerative power of affected parts 
in some cases. 

Epithelioma. — Accompanied with dilated or numerous capillaries, con- 
siderable redness, burning pains and a tendency to bleed freely on slight irri- 
tation of the affected surface. Especially when originating from hypersemic 
lesions with bloody contents or bleeding easily, particularly if situated on the 
face or about the orifices of the body. 

Carbolic acid may be given for its remedial effects on the skin in the third 
to sixth decimal attenuation. 

CAUSTICUM 

Either weakness or anaemia is a fundamental characteristic of this drug, at 
least for all chronic conditions. The weakness may be largely motor and local 
with a distinct affinity for the organs of circulation, the throat, bladder and 
face, but the dislike and apparent inability to make effort is often general in 
nature. It may correspond somewhat to the rheumatic or gouty diathesis, and 
a sour sweat is symptomatic. It produces its effects on the skin through the 
vaso-motor nerves, causing circumscribed congestion, inflammation and less 
often papillary hypertrophy. In the skin itself there may be found any of the 
many forms of pruritus from the simple tickling to the most aggravating bur- 
rowing sensation. Symptoms are worse at night, from warmth of bed. are 
temporarily relieved by scratching and by lying down. Sometimes at night 
a type of restlessness appears which is not relieved by motion. 



542 CHELIDONIUM 

The phases of eczema suggesting causticum' are not often seen, and then 
there must be some non-eutaneous indications also to justify the selection of 
this drug. It is probable that similar changes in the qualitv and quantity of 
the secretions of the skin, as found under this drug, are often exciting causes 
of eczematous inflammation, because the folds of the skin (imprisoning sweat), 
between the thighs, back of the ears, under the breasts and at the vertex under 
the hair are favorite sites indicating causticum. A similar relation holds for 
eczema of the upper lip from nasal discharges, and about the nipple from dis- 
turbance of secretion there. Location, however, is of less importance, except 
as related to cause, than the sensations, their variations and the form of lesion. 
The latter is usually vesicular — a moist, weeping surface becoming more or less 
covered with crusts. Papular and papulo-pustular eczema wherever located 
may occasionally show indications for causticum. Aggravations from open air 
or on exposure of the skin to air are suggestive features. 

Rosacea. — Eedness and pimples chiefly on tip and wings of nose and be- 
tween eyes ; associated with acid dyspepsia, sour eructations long after eating, 
or with urinary disorders indicating causticum; drawing or tense sensations. 
In late stage when wart-like enlargements appear on nose. In gouty or rheu- 
matic subjects. 

Syphilis. — Secondary hyperaemic generalized eruptions, attended with par- 
alytic weakness, loss of hair, sensitiveness or soreness of the buccal membrane. 
Symptoms worse at night. 

Verruca. — Eeddish. warty growths on finger tips, about nails, nose or eye- 
brows. Eheumatic subjects with sour sweat and restlessness at night. 

Causticum acts best on the skin in the low attenuations, first to sixth 
decimal. 

CHELIDONIUM 

Through its action on the liver and other organs of secretion and excretion, 
chelidonium may induce a retention diathesis (toxaemia), derange the func- 
tions of the skin and give rise to inflammatory papules, vesicles, pustules, etc. 
Jaundice may or may not be present, but the itching sensation in small areas 
is like that observed with jaundice staining. The sensory symptoms in the skin 
which may vary widely from a typical itching, are almost always worse morn- 
ing and afternoon, from sitting (in dependent parts), continued pressure, and 
are better from rising, after eating, from driving and other passive forms of 
motion. The hepatic and gastro-intestinal symptoms of this drug are always 
to be kept in mind in any case of eruptive disease suggesting its use. Lassitude 
and drowsiness during the day are general indications. 

Seborrhceic dermatitis which simulates somewhat lupus erythematosus, 
situated on the face, scrotum or about the anus, occurring in the sallow com- 
plexioned or phlegmatic, attended with corrosive burning, biting, stinging, itch- 
ing, or soreness, may require chelidonium; especially adapted for chronic 
cases which tend to assume a malignant type. 



CHININUM 8ULPHURICUM 

Acne. — When some of the genera] symptoms of chelidoninm are present, 

and the eruption occurs on the face in small groups of rerj Benaitiye papulo- 
pustules. 

The eczema calling for this remedy is usually situated on the dependent 
parts of the body, such as the scrotum aud legs, where the blood in over-charged 
vessels circulates less rapidly. The form of lesions is often vesicular, attended 
with considerable heat and swelling of the skin, and if not arrested is apt to 
pass into the red, angry appearance of the surface, described as eczt ma rubrum. 
Sometimes a papulo-pustular eczema on the face, trunk or thighs presents a 
symptomatic likeness to chelidoninm. 

Carcinoma cutis, Epithelioma, Paget's disease. — Yellowish-gray com- 
plexion. Painful lesions in the skin with burning sensations, worse morning 
and afternoon, better at night. Spreading ulcers with offensive discharge. 
Diurnal lassitude and sleepiness. Hepatic and gastric symptoms. 

Chelidonium should be given in a low attenuation for most types of skin 
disease. Externally one part to four to ten of pure glycerine is often useful. 



CHININUM SULPHURICUM 

Quinine in sufficient doses induces an auto-toxaemia by its inhibitory action 
on protoplasmic processes and by retarding the elimination of waste (poison- 
ous) products from the system. Reflexly or otherwise, the skin of susceptible 
persons may become congested or inflamed, and characterized by the rapid 
appearance of more or less extensive erythema followed by desquamation or 
papular, nodular and sometimes vesicular eruptions. Very similar results may 
follow when other factors cause effete or other poisons to be retained in the 
system. Some general indications for quinine are apprehensiveness of impend- 
ing danger, whirl-like vertigo, sensitiveness of the upper part of the spine to 
pressure, oppression of the chest and a tendency to periodicity in the onset or 
aggravation of symptoms. The location of cutaneous eruptions may be general, 
though a preference is shown for the face, extremities, chest, neck and genitals. 
Sensations of itching, pricking, chilly creeping or crawling and tension may be 
felt ; aggravations are apt to occur at night, from pressure or friction and from 
exercise ; some relief is felt from scratching and from change of position. 

Erythema scarlatiniforme. — Bright red efflorescence, beginning on face, 
neck, chest or extremities, spreading to other parts and preceded by or accom- 
panied with fever; with itching, pricking or creeping sensations, worse from 
touch, exercise and at night; with pufhness of eyelids, face or 1< dally 

in cases which tend to recur or persist and are always followed with abundant 
desquamation. 

Erythema multiforme. — Flat, lumpy, itching papules in patches on back 
of hands; vivid redness with swelling and itching on face and limbs; lesions 
sensitive to touch, worse at night from exercise: especially when lesions tend to 
vesiculate or become purpuric. 



544 CHLORALUM 

Urticaria. — Onset attended with swelling or oedema of the face ; rapid out- 
break and general distribution of eruption, worse on extremities, neck and face ; 
in malarial cases subject to periodic attacks or' attacks from some slight indis- 
cretion in diet. Sensation of itching, pricking, burning, tingling, worse from 
pressure, friction, exercise, better temporarily from change of position and 
scratching. 

Purpura, P. hemorrhagica. — Sudden attacks; lesions on extremities or 
trunk, variable in size and painful to pressure ; sensitiveness of dorsal vertebrae 
to pressure; apprehensiveness of patient regarding attack; oppressiveness of 
chest ; bloody diarrhoea, bleeding from gums or other parts of the mucous mem- 
brane. 

This remedy should be administered in a medium attenuation, third or 
fourth decimal. 

CHLORALUM 

Besides the well-known hypnotic effect of chloral, it depresses respiration 
and circulation, and in susceptible subjects causes paralysis of the vaso-motor 
centres, consequent circumscribed or diffuse redness of the skin, less commonly 
papules, wheals, and rarely vesicular or hemorrhagic lesions. The favorite 
locations for chloral eruptions are the face, neck, chest, extensor surface of the 
knees, wrist, elbows and ankles. Sensations of burning, itching, fullness and 
throbbing are most common. Aggravations of the eruption after hot drinks, 
stimulants, and after eating are characteristic; palpitation may be felt at the 
same time and sensations are usually worse at night. 

Erythema multiforme. — Bright or dusky redness of the face, varying in 
intensity, sometimes associated with twitching of facial muscles; dusky red 
patches on chest and extensor surface of extremities ; fluxionary redness always 
worse from hot or stimulating drinks and after food; with exudative papules 
which coalesce to form wheal-like patches ; with burning or itching sensations, 
worse at night; variegated red patches, afterward yellowish with lighter 
patches between. 

Urticaria. — Bare cases following free use of hot drinks or stimulants; 
smaller lesions tend to coalesce when associated with considerable erythema; 
burning, itching and throbbing sensations. 

. Purpura. — Associated at the onset with an erythematous or urticarial erup- 
tion, which subsides, leaving characteristic purpuric lesions widely distributed ; 
following intoxication or prolonged and free use of stimulants; sensations of 
fullness and throbbing, increased by hot drinks. 

The third decimal attenuation is suitable strength for most cases to which it 
is adapted. 



CICUTA \ [ROSA CI81 i S 546 



CICUTA VIROSA 

Cowbane is a cerebrospinal irritant, causing muscular twitching, convul- 
sions and derangements of innervation and circulation The -kin may suffer 
reflexly from intense circumscribed hyperemia, characterized by the appear- 
ance of dark red elevated lesions on hands and lace, which turn darker or occa- 
sionally become superficially inflamed and result in vesicular or pustular 
formations. Sensations of burning, itching, drawing, stinging or crawling are 
common, and are worse from touch and sitting ; better from pressure and 
scratching. 

Erythema multiforme. — Occurring in neurotic subjects with muscular 
twitchings; dark red elevations on face with burning pain on touch, cluster of 
red, smooth spots on back of hands, lessened by pressure, later becoming darker ; 
especially when lesions tend to coalesce, and some to become vesicular; with 
itching, drawing or crawling sensations. 

Impetigo, I. contagiosa. — Pea-sized elevated lesions on face and hands, 
rapidly become sero-purulent and form honey-colored crusts. Burning or itch- 
ing sensations on touch, relieved by scratching contiguous skin. Especially in 
neurotic children and when lesions tend to coalesce, multiply or extend. 

The third decimal is a suitable attenuation for most cases of cutaneous 
disease. 

CISTUS 

This drug appears to act on glandular tissue and the peripheral nerve cen- 
tres, causing irritation or infiltration of the former and sensory and vaso-motor 
disorders of the cutaneous membranes. The macular, papular and vesicular 
lesions occur along the distribution of peripheral nerves, especially of the right 
side of face and trunk, attended with sensations of soreness, burning, neuralgic 
pains, and sometimes with dyspnoea, worse on lying down and better from 
motion. Extreme sensitiveness to cold is an important general indication for 
this drug. 

Herpes facialis. — Worse on right side; in scrofulous or rheumatic subjects 
extremely sensitive to cold. 

Herpes zoster. — Eight side of face or intercostal region, with sore burn- 
ing, neuralgic or rheumatic pains which continue after appearance of eruption 
or extend to non-eruptive regions, with attacks of difficult breathing, worse 
on lying down; great sensitiveness to cold, especially in rheumatic or scrofulous 
persons. 

Cistus should be administered in a low attenuation, first or second decimal. 



546 CLEMATIS— COCA 



CLEMATIS 

The pains of this drug simulate those of rheumatism, its action on the 
lymphatics that of some fresh infection, while its tendency to produce herpetic 
lesions on the skin recalls the "herpetic diathesis" of old writers. Vesicles may 
be preceded by erythema or papules, and, again, may terminate in pustules or 
crusts, but the type of eruption is more distinctly herpetic than otherwise. The 
favorite location is at the occiput near the hair line; next in order are the 
anterior parts of the scalp, the face, and rarely the eruption may be generalized 
over the trunk and extremities. The sensations often vary from a typical 
itching to a pulse-like stinging, crawling, quick sticking or tickling. The 
tendency to be worse on the hairy parts of the skin, from cold bathing, from 
warmth of bed and in chronic eruptions, a monthly aggravation (said to be 
coincident with the new moon) is quite marked. 

The forms of eczema to which clematis is adapted are briefly indicated by 
the foregoing. A proclivity to rheumatic or lymphatic affections from inef- 
fective elimination, or from suppression of discharges (catarrhal, gonorrhceal, 
etc.), should favor the selection of this remedy. 

Herpes. — Eecurrent on face or genitals, eruption on or extends to hairy 
parts; pruritic sensation worse from warmth of bed at night; in rheumatic 
subjects, herpes progenitalis associated with genito-urinary affections, especially 
from suppressed gonorrhoea or other morbid discharge. 

Herpes gestationis, Impetigo herpetiformis, Dermatitis herpetiformis. 
— Clematis may be indicated in these affections when occurring in persons of 
a rheumatic constitution with monthly recurrences or aggravations, a tendency 
to invade the hairy parts ; attended with pruritic sensations, worse from warmth 
of bed at night, and especially if the onset was preceded by the suppression of 
some discharge or evidences of a fresh infection. 

Clematis may be used low or comparatively high, according to the sensitive- 
ness of the patient. The second decimal is more often employed. 



COCA 

This drug produces finally on the system a sort of premature aging resem- 
bling somewhat the nervous debility which follows from mental over-activity, 
accompanied with insomnia, emaciation, dyspepsia and nervous disturbances. 
The skin generally may have a tense feeling with a lessening of color and 
secretions; while on unusual locations erythematous, papular, tubercular or 
wheal-like lesions may occur. Certain relief of symptoms is experienced from 
taking wine, from being in the open air and from riding. 

In anidrosis and asteatosis partial in character when the above or similar 
conditions are found, they may be relieved by the use of coca. 



0OCCULU8 ..IT 

Erythema multiforme. — Circumscribed erythema, papules, tubercles or 

wheals in unusual locations; in the debilitated or prematurely old; when symp- 
toms are better from wine, open air and while riding. 

Urticaria, U. pigmentosa, Purpura.— With lesions in unusual locations; 
occurring in the neurasthenic or prematurely old; sensations and Bymptoms 

generally relieved by stimulants, open air and from riding. 

Coca should be employed in a low attenuation, first or second decimal, and 
sometimes in the tincture. 

COCCULUS 

This drug, through a toxic effect on the cerebro-spinal axis, acts especially 
on the motor nerves producing spasms, local disturbances of digestion, circula- 
tion, vertigo and various nervous phenomena. 

On the skin its action is almost purely reflex on the peripheral blood- 
vessels, inducing hypcramiic, macular, papular and pustular lesions, especially 
of or about the glandular structures. The favorite locutions are the face, neck, 
shoulders, chest and inner thighs. Sensations in the skin are not important; 
sticking, burning, itching and crawling are most common. Aggravation of 
most symptoms from riding, all exertion, eating, drinking, after smoking, etc., 
are significant, but the special (clinical) modality of the skin is the intolerance 
of exposure to either cold or warm, open air, and in a less degree to artificial 
extremes of temperature. 

Hyperidrosis of hands. — Hysterical subjects, worse mornings, from cold 
or heat, and relieved by passive friction of the parts. 

Acne. — Much redness of the area of skin involved, especially of the face, 
which becomes worse from exposure to either heat or cold, and particularly if 
other neurotic symptoms of cocculus are found. 

Onychia. — Hot, burning sensations about the nail with other symptoms 
of cocculus. 

Urticaria. — Hard lesions, burning and itching as from nettles, worse on 
exposure of skin to air in undressing, etc., from gastro-intestinal irritation 
or absorption of toxins of indigestion. 

Rosacea. — Associated with flatulent dyspepsia, mental dullness, menstrual 
disorders or sick headaches; symptoms worse from riding, eating, cold drinks 
and surface conditions always from exposure to either heat or cold, with spinal 
irritation and hyperesthesia. 

This drug may be given in the third decimal, not higher, and in some 
cases the first or second attenuation is preferable. 



548 COLCHICUM 



COLCHICUM 

In general, it is interesting to note that this drug produces symptoms of 
acute attacks of rheumatism and gout. Violent gastro-enteritis, profound 
depression of the heart and of the temperature are also noted from the use 
of physiological doses. Colchicine, the alkaloid of colchicum, has been found 
to give greater satisfaction in the treatment of cutaneous disorders than col- 
chicum and should always be prescribed on the patient's general condition 
rather than on surface indications. The gouty and rheumatic diatheses are 
the most important item to consider. The lesions are not typical; the same 
may be said of location. Sensations include sticking, crawling, itching and 
burning, often aggravated by scratching, with the result that the irritation 
seems to be driven to another part of the skin. 

Seborrhceic dermatitis. — Gouty or rheumatic diatheses in middle aged 
or old people who exercise very little and whose glandular system is inactive. 

Acne simplex. — Occasional cases associated with an excess of uric acid, 
indolent lesions with a tendency to become indurated. 

Acne indurata. — Pruritus may be a feature caused by excess of urea and 
uric acid. 

Erythema multiforme. — A frequent cause of this disease is the retention 
of the waste products of metabolism, and the rheumatic tendency may lead 
to the use of colchicum. 

Eczema. — Squamous, fissured and verrucose types, chronic and indolent in 
their course, presenting the typical aggravation from scratching. 

Psoriasis. — Complicated by seborrhceic dermatitis in rheumatic and gouty 
subjects. The lesions are of the indolent, inveterate, scaly type. The compli- 
cating condition causes marked subjective sensations, worse from scratching. 

Dermatitis exfoliativa. — Associated with general conditions. 

Urticaria. — Arising during the course of a rheumatic or gouty attack with 
the tendency of the subjective sensations to appear at different places from 
those originalty scratched. 

Pruritus. — Generalized or localized, associated with uric acid and its 
causal factors. 

Herpes zoster. — Associated with general conditions. 

Rosacea. — Indolent papular eruption with burning, worse from scratching. 
Uric acid diathesis. 

Pemphigus. — Gastro-enteritis of the severe type peculiar to colchicum. 
Great prostration and weakness. 

Colchicum may be used in the first to third decimal, while colchicine is 
usually prescribed in the second to sixth decimal when used for cutaneous 
conditions. 



COMOCLADIA OONIUM 549 

COMOCLADIA 

The action of this drug on the skin resembles rims fox. in producing ery- 
thema, swelling and papular eruptions; it lacks the power of the latter in 
causing vesieulation, but exceeds it in provoking pigmentation or suppuration, 
the latter particularly on the legs. It causes sensations of heat, burning, itch- 
ing, stinging, crawling and tension, which may shift rapidly from one spot to 
another. Aggravations may occur from touch, warmth, rest, and in the morn- 
ing and evening. Relief may follow from motion, rubbing, scratching and in 
the open air. The favorite location for diffused redness and swelling is the 
face; for circumscribed patches, the trunk and lower extremities; and for 
suppurating lesions, the legs. 

Erythema multiforme. — Eedness and swelling of the skin followed by 
unusual pigmentation; of the face with recurring puffiness about the eyes; 
general, or on sides of trunk and outer part of extremities; with burning, 
itching, stinging or crawling, which shift in intensity from one part to another, 
generally worse from touch, warmth and rest, and tetter from motion, scratch- 
ing and rubbing ; fugacious erythema — from above downwards. 

Comocladia may be indicated in acute erythematous eczema of the face 
with marked swelling of the skin, partly closing the eyes; or for chronic ery- 
thematous eczema of the face, characterized by a frequently recurring puffiness 
or swelling about the eyes (cro talus). 

It is also adapted to a papular eczema of the trunk and extremities, which 
remains papular — not becoming vesicular or pustular. 

Cures have been observed from this drug in attenuations from the first to 
the thirtieth. 

CONIUM 

Acting chiefly on the peripheral nerves (motor and trophic), conium de- 
ranges the vegetative functions of the body, and renders the individual unfit 
for physical or mental effort. The changes in nutrition cause the glands to 
enlarge as in scrofula; the complexion to become pale, yellow or sallow, as 
in old age. Circumscribed areas of the skin may change in color, the hair 
falls out, and papular, vesicular, pustular or even gangrenous spots appear. 
The most common sensations in the skin are burning and itching, but almost 
any abnormal sensation may be felt. Aggravations occur from scratching, 
washing, perspiration, sitting and at night. Eelief sometimes follows from 
rubbing and from moving about. The favorite locations of conium eruptions 
are the genital regions, the face and the hands (except macules may be gen- 
erally distributed over the trunk and extremities). These also are the regions 
where sweating is apt to be most abundant, particularly with sleep at night 

Hyperidrosis or chromidrosis.— Sweat ing abom" the perineum, genitals or 



550 COPAIVA 

axilla at night on falling asleep, sometimes offensive, in the neurotic or ca- 
chectic individuals, especially old people or the prematurely aged. 

Eczema of the face, hands and genitals with papulo-vesicular lesions, 
occurring in scrofulous or neurotic individuals and presenting the character- 
istics of conium. have been cured by its use. 

Pruritus. — Erratic itching of any part; after active exercise or perspira- 
tion, worse from washing, at night, better from moving about and from rub- 
bing. 

Urticaria papulosa. — After violent bodily exercise, with evanescent sting- 
ing, burning or itching in a single spot at a time ; associated with hepatic dis- 
turbance, yellowish skin, etc.; occurring in old people or in scrofulous types 
and tendency to chronicity. 

Trophic ulcers. — In spontaneous forms of ulceration with or without 
gangrenous tendencies, conium may be indicated by its action on the trophic 
nerves and other features of its pathogenesis. 

Syphilis. — Primary stage, indurated lesion, followed soon by glandular 
swellings. Tingling, pricking or stitching sensations, worse at night, during 
rest and on hang down, better from motion. Especially in the prematurely 
old or scrofulous subjects with pale yellowish complexion. 

Paget's disease. — Old women of tight, rigid fibre or of scrofulous type. 
Inflamed, indurated patch on areola or nipple, with burning, itching or tin- 
gling sensations, worse at night, sitting ; better from walking about and gentle 
rubbing. 

Conium may be administered in the sixth decimal or lower attenuation. 
The more marked the changes in the texture of the skin the lower the attenua- 
tion should be. 

COPAIVA 

This drug acts prominently on the skin and on the mucous membrane of 
the urinary tract, preceded or attended at the onset with febrile symptoms and 
sometimes hysterical disturbances. On the skin, circumscribed lenticular 
patches of redness (deepest at the centre) and papular, nodular, bullous, pus- 
tular and sometimes hemorrhagic lesions have been observed. The location 
of eruptions may be general, though the joints, back of hands, feet, face, chest, 
legs and arms are sites of preference. Sensations of itching, pricking, tickling, 
biting, burning or crawling are commonly felt, and are usually worse morning 
and evening, and from touch. 

Erythema neonatorum. — Eedness of the skin with or without febrile dis- 
turbance, the color fading to yellow and disappearing without desquamation : 
with minute hemorrhagic points. 

Erythema multiforme. — Uneasiness, chilliness, then fever followed by 
red lenticular eruption, with itching and pricking, color disappears tempo- 
xarily on pressure, lastly mottled appearance of surface : round spots with 



CORNUS CIRCINATA -CROTALUS BORRIDD8 561 

uneven edges and normal skm between; on back of hands, wrista, feet, anklet 
or knees; smooth papular eruption, with pointa of deeper color, sometime! 
becoming confluent; especially when associated with characteristic urinary or 
gastric disorders, and symptoms in general arc worse morning and night. 

Urticaria. — Beginning about the articulation, with small and large lesions 
and considerable redness, attended with fever and restlessness; associated with 
scanty urine loaded with sediment; dryngSfl and heat of skin with violeni 
biting, itching sensations, worse from touch. 

Purpura. — Onset attended with febrile symptoms, restlessness, bloody 
urine, bruised or rheumatic pains and pruritic sensations; pin-head-sized hem- 
orrhagic lesions surrounded witli a hyperamiic zone. 

Pemphigus foliaceus. — "Modified pemphigus over whole body, beginning 
at flexure of joints, the bulla? aborted where the skin was thin, the discharge 
excessive, offensive, viscid, then general desquamations." Bullous eruptions 
on an erythematous surface, with non-cutaneous symptoms indicating copaiva. 

Copaiva acts well in medium attenuations, third to sixth decimal. 



CORNUS CIRCINATA 

Vesicular eruptions associated with chronic affections of the liver, spleen, 
intestines, malarial cachexia, chronic diarrhoea or aphthous stomatitis may be 
cured with this drug. 

Vesicular eczema of the face, in infants suffering with nursing sore 
mouth, or from diarrhoea, and attended with only moderate itching of the 
parts, has yielded to this remedy. 

Herpes facialis. — Of infants or young children associated with the above- 
named or similar conditions. 

The sixth decimal is the best single attenuation. 



CROTALUS HORRIDUS 

This venomous poison introduced into the human body acts quickly and 
profoundly upon the nervous system. If the dose is not rapidly fatal it soon 
produces decomposition of the blood and a consequent tendency to local hemor- 
rhages, inflammations and derangements of nutrition similar to those observed 
in asthenic forms of disease. As a remedy ii probably finds most use in the 
so-called zymotic maladies (yellow fever, scarlet fever, etc.). which either 
overwhelm the nervous system by the intensity of their onset or pursue a 
malignant course; but there may be phases in the course of many cutaneous 
affections, due to alterations in the blood or to an invasion of the tissues by 
poisons generated without or within the body, which indicate its employment 

Of the lesions produced, color changes of the skin may be pigmentary with 



552 CROTALUS HORRIDUS 

or without hemorrhages, a mixed or a venous hyperemia with or without in- 
flammation. If the latter prevail it may result in the formation of vesicles, 
pustules, tubercles, gangrene or ulcers. Location is not characteristic. Sensa- 
tion is more often described as stinging, tension, soreness, sticking or simply 
painful rather than the more common itching. 

Hasmatidrosis. — Bloody sweat either from hereditary tendencies (hgemo- 
philia), acquired blood states or neurotic disorders may be accompanied with 
some symptoms indicating crotalus. It is especially adapted to cases of this 
nature due to some septic poison or peculiar nervous disturbance of the circu- 
lation, which sometimes occurs in women at puberty, the menopause, or with 
dysmenorrhcea. Petechia? or other signs of hemorrhage are usually present 
also. 

Acne. — Papules and pustules with purplish areolae and other signs of a 
sluggish or weak circulation, particularly for amenorrhceic, dysmenorrhceic 
or hysterical young women. 

Erythema caloricum (chilblains). — On hands and feet, with swelling, 
stinging, sticking, tension or soreness ; recurring each year in the same place ; 
in the weak or cachectic, with dark color of affected skin threatening gangrene. 

Erythema multiforme. — In persons of weak circulation; local swellings 
attended with fever, followed by green, yellow and bluish spots after the swell- 
ing ceased; diffused redness of sides of body and on lower extremities with 
soreness, leaving the surface mottled and disappearing from above downwards. 

Vaccination eruptions. — Occurring in the weak or anaemic within three 
days after inoculation, eruption resembling erythema multiforme ; after devel- 
opment of the virus, small purpuric spots, with faintness, irregular pulse and 
dizziness; from subsequent infection through the wound — erysipelas, cellu- 
litis, furunculosis or gangrene. 

The type of eczema indicating crotalus is not common. It has cured erythe- 
matous eczema of the face, occurring in the old or cachectic, characterized by 
much swelling and tension of the face, especially about the eyes, and restless- 
ness at night. Periodicity in attacks or aggravations of the swelling has been 
found a good keynote. Barely crotalus is indicated in vesicular eczema of the 
arms, attended with considerable swelling and discoloration of the skin. 

The rare affection, dermatitis gangrenous infantum, has been described 
with symptoms (hemorrhagic vesicles, bulke, gangrenous crusts, etc.). which 
point to crotalus as a remedy. 

Purpura hemorrhagica. — Bleeding from any or all mucous outlets with 
petechial spots in the skin, worse on lower extremities with irregular and weak 
heart action, faintness and vertigo; especially valuable in cases consecutive to 
asthenic types of disease or due to septic infection. 

Insect bites, Furuncle, Carbuncle, Anthrax, Dissection wounds. — Deep 
seated, bluish, blackish, gangrenous lesions, with bright or dark red areola; 
scant, dark, bloody or ill-conditioned discharges; stinging, throbbing, tense, 
sore sensations, sometimes relieved by pressure and dependent position: at- 



CROTON TIQLIUM CUNDURANOO 

tended with prostration or signs of Bepticssmia. Especially valuable for bitea 

of insects with erysipelas-like redness and swelling, for boils and carbuncles 
following vaccination or septic inflammation, and for dissection wounds 
spreading to the subcutaneous tissue and lymphatics. 

Erysipelas. — Widely extending redness and swelling of the skin from a 
poisoned wound or sore; secondary blisters filled with a darkish fluid ; attended 
with weakness, faintness, vertigo and tardy resolution of the affected parts. 

Crotalus, unlike lachesis, probably acts best in medium attenuations, third 
to sixth decimal. 

CROTON TIGLIUM 

Croton oil applied to the mucous membrane of the skin excites a catarrhal 
inflammation. Given internally it seems to have an elective aflinitv tor the 
skin of the face and external genitals, producing a dark red erythema, w- 
and pustules, accompanied with corrosive itching, smarting, burning, tickling 
and other pruritic sensations. These are worse night and morning, from wak- 
ing, touch, washing and exposure to the air. 

Croton tig. is adapted to the treatment of acute or subacute eczema of the 
face — erythematous or vesicular; or of the external genitals — erythematous, 
vesicular or pustular, when the sensations and modalities correspond. 

Herpes. — Of face or genitals accompanied with corrosive itching or burn- 
ing, greatly aggravated by friction, thus preventing scratching, sometimes re- 
lieved by gentle touch or pressure, with offensive, yellow, plastic exudation, 
which causes intense burning by contact, especially valuable for herpetic 
eruption about the eyes involving the conjunctiva. 

Herpes zoster. — Of muscular parts, evolution of eruption attended with 
intense burning, smarting, soreness, etc., with extreme sensitiveness to contact 
and friction. 

Dermatitis herpetiformis, Impetigo herpetiformis, Herpes gestationis. — 
Croton tig. may be indicated in these maladies when the course of the eruption 
is marked by severe sensations ; the exudation becomes yellow, offensive or ex- 
coriating and the lesions predominate on or about the genitals or over the more 
muscular regions of the body. 

The sixth decimal is a serviceable attenuation for most cases. 



CUNDURANGO 

While satisfactory knowledge regarding the action of this drug on the 
human tissues is lacking, it appears probable that it excites activity in abnor- 
mal tissue or formations and leads to local changes somewhat like effects due to 
specific or malignant types of disease. On the skin congenital formations may 
be stimulated, inflamed or increased, macules, papules and pustules appear 



554 CUPRUM ARSENICOSUM— CURARE 

and at or near the mucous outlets fissures develop. It may therefore prove 
beneficial or curative in certain unusual aspects of disease. 

Syphilis. — May supplement other remedies when fissures form about the 
muco-cutaneous outlets. 

Naevus pigmentosus, N. vasculosus. — Increase in color or size of con- 
genital growths, especially when associated with irritations of the mucous 
membranes and tendency for cracks to form at corners of the mouth. 

Epithelioma. — Of lips or anus, characterized by painful or repeated oc- 
currence of fissures or fissure-like ulcerations. Also for epithelial growths 
originating apparently from irritation or congestion of a pigmentary mole, 
with early tendency to warty growth or cracking. 

Carcinoma cutis. — Ulcerative stage when fissures form. 

Verruga. — Cundurango may be adapted to the treatment of some cases 
of 'this tropical disease. 

Cundurango should be given in a low dilution or tincture for its remedial 
effect on the skin. 

CUPRUM ARSENICOSUM 

This salt exerts its greatest influence upon the gastro-intestinal tract, 
causing colic, cramps, vomiting, purging and nausea. Its action upon the skin 
is not well understood, although itching of the arms and legs, pustules, oedema 
and furuncles have been reported. 

Eczema. — When a scaly, chronic patch of the palm of the hand is present, 
this remedy will often benefit. 

Syphilis. — A slowly spreading squamous syphilide of the palm, resem- 
bling psoriasis, has responded to this salt. 

Cuprum arsenicosum should be given in the sixth decimal for most cutane- 
ous cases, although it may be necessary to go as low as the third decimal. 



CURARE 

Arrow poison, according to Claude Bernard, paralyzes the musculo-motor 
and vaso-motor nerves. It appears to act primarily upon the peripheral nerves, 
and has an affinity for the feet and. ankles. 

Thus it shows a pathological relation to certain conditions included under 
keratosis palmaris et plantaris. The sensations of soreness, tenderness, 
numbness credited to this drug have also been noted in the disease. Aggra- 
vation of conditions following washing are also common to both, though not 
limited to the same regions. 

This remedy does its best work in the attenuations from the second to the 
sixth decimal. 



CYCLAMEN DIGITALI8 



CYCLAMEN 

This drug acts chiefly on the gastro-intestina] and the genito-urinary 
tracts, inducing secondary anaania and a rorietj of reflexes. Thus the sensory 
nerves of the skin become paraesthetica and on the face circumscribed erythema- 
tous, papular and pustular lesions appear. A certain though temporary relief 

from pruritic sensations is obtained from rubbing or scratching. 

Acne simplex or indurata. — Acne in young women, due to menstrual dis- 
orders, who are subject to frequent depression, headache, vertigo, nausea: <>r 
in older women with similar symptoms due to dyspepsia. Some symptoms are 
aggravated by motion, going out of doors, on waking, eating l'at food, and are 
relieved by quiet indoors and on appearance of the menses. 

Pruritus. — Associated with menstrual or gastro-intestinal disorders; itch- 
ing changing from one part to another, worse from increase of indigestion, 
menstrual disturbance, at night in bed, relieved by scratching the pari until 
sore and on appearance of menses. 

This drug may be administered in the sixth decimal first, and then in a 
lower attenuation if an effect is not obtained. 



DIGITALIS 

Digitalis acts through the vaso-motor system and produces well-known 
effects on the heart and arteries, secondary anaemia of some parts and hyper- 
aemia of others. From the latter conditions arise a variety of disorders. The 
skin becomes pale and grayish in hue and cool or cold to touch: the tatty 
secretions are more consistent, retained in the follicles, and sometimes decom- 
pose or are invaded with pus cocci. 

Comedo. — In young persons with pale complexion, slow pulse, symptoms 
of spinal anaemia, nervous depression or spermatorrhoea. The comedones may 
suppurate rapidly, but do not lead to much redness. 

Acne simplex. — Papules and pustules always beginning with comedo, ap- 
parently from decomposition of the latter, and with similar Bymptoms. 

Digitalis should be given in most cases in the second decimal, others may 
need the first attenuation. Xo effect on the skin can be expected from high 
dilutions. 



556 DULCAMARA 



DULCAMARA 

The pathogenesis of dulcamara is related to surface affections which are 
reflex or "critical" in nature, particularly the reflexes excited or aggravated 
by changes to cold and damp weather; the latter really act to suppress func- 
tions of the skin and exposed portions of the mucous membrane, and are 
usually followed by reactions toward the surface. The effects may appear 
as erythematous, papular and sometimes vesicular lesions. The attendant 
sensations may vary widely- — tickling, burning, creeping and itching being the 
most commonly experienced. Aggravations from cold and wet weather are 
always to be associated with this drug, and warmth of room or bed may also 
increase abnormal sensations, as may also the use of coffee and eating. Gen- 
eral betterment of eruption in warm weather, however, is notable, as is tem- 
porary relief of sensations from cold. These contradictions are apparent only, 
as they are due on the one hand to general and on the other to local influences. 

Chromidrosis. — When associated with pruritus or urticaria which may 
show characteristic aggravations. 

Erythema multiforme. — Attacks without fever at the beginning of winter 
or in cold, wet weather ; with burning, itching, tickling or creeping sensation. 
worse from coffee, perspiration, warmth of room or bed, temporarily relieved by 
cold applications; with lesions resembling nettle rash, but more persistent in 
course. 

Dulcamara has anti-catarrhal virtues which adapt it to the treatment of 
eczema of the face, head, hands or arms. It is especially useful in eruptions of 
these parts at or before the menstrual periods or consecutive to some disorder 
of other organs or functions. The lesions may be erythematous, papular or 
more often vesicular, forming dirty or brownish crusts, but they are rarely or 
never pustular. The attendant sensations may vary widely, tickling, burning, 
creeping and itching being the most commonly experienced. Aggravations of 
lesions from cold and wet weather are always to be associated with this drug, 
and warmth of room or bed may also increase abnormal sensations. General 
betterment of eruptions in warm weather, however, is notable, as is temporary 
relief of sensations from cold. These contradictions are apparent only, as they 
are due on the one hand to general and on the other to local influences. Pruri- 
tic sensations are often made worse by coffee, by sweating of the parts, and 
sometimes after eating. 

Pruritus. — Always worse in cold, wet weather or beginning of winter, 
from exposure to cold in undressing, coffee, sometimes relieved by cold appli- 
cations and in warm weather. 

Urticaria.- — Generalized without fever; after exposure to wet and cold, or 

in cold weather ; with violent itching, worse from warmth of room or bed coffee, 

12 to 3 a.m., better, from cold applications and from persistent scratching. 

Herpes, H. zoster, Pemphigus.— When apparently precipitated by expo- 



ERYNGIUM AQUATICUM EUPHORBIUM FAGOPYRUM 

sure to cold and wet and exhibiting some of the above characteristics, dulca- 
mara should be considered m choosing a remedy. 

Dulcamara acts best in a low attenuation, second to third decimal 



ERYNGIUM AQUATICUM 

"Sweat of urinous odor in evening." 

Uridrosis. — This drug should be studied in those rare eases where in the 
absence of kidney disease the equilibrium between the urinary and perspiratory 

functions is disturbed and the sweat has a urinous odor. Sexual weal 
pollutions, or a slight urethral discharge from ordinary causes are good con- 
comitant indications. 

The lower attenuations should be employed. 



EUPHORBIUM 

Topical applications of this substance cause inflammation of the skin with 
a marked tendency to vesiculation and later low or destructive forms of inflam- 
mation. Many subjective symptoms are credited to it from internal doses. 

It may be thought of as a remedy for erysipelas of the face attended with 
high fever and early vesiculation. It has been employed locally with benefit 
for indolent and gangrenous ulcers, ulcerating carcinoma and epithelioma 
of the skin. 

Probably the best effects may be obtained by giving a low attenuation in- 
ternally and from applications of a crude preparation to the diseased surf; 



FAGOPYRUM 

Buckwheat acts on the mucous membrane of the respiratory trad, causing 
fluent coryza and general burning and itching of the membranes. It also 
influences the peripheral cutaneous nerves, causing varied sensations, especially 
persistent itching, aggravated by scratching, by touch and alter retiring. 
Amelioration occurs in the open air. Lesions consist of erythema and papules 
which never become pustules. 



Erythema multiforme. — Erythematous type; marked itching and Bore- 

ness, better in the open air. 

Eczema. — Erythemato-papulae or simple papular type with typical aggra- 
vations and ameliorations. 

Fagopyrum may be used in the third decimal with good results. 



558 FLUORICUM ACIDUM 



FLUORICUM ACIDUM 

This tissue drug acts on fibrous and fibro-elastic structures, especially on 
the veins, and seems to create a predisposition to deep-seated rather than 
superficial disease, whatever the part involved. In skin diseases it is particu- 
larly adapted to the cure of affections in a measure due to venous stasis or vari- 
cosity. The appendages of the skin are affected by lack of nutrition, hyper- 
trophic formations arise from misdirected nutritive processes, or inflammation 
begins and persists from lack of vital resistance. Pruritic sensations are com- 
mon, varying to crawling, burning, sticking, fullness, throbbing, etc. Aggra- 
vations, occur at night, on warm days, in dependent parts, from standing and 
sitting. Amelioration occurs temporarily from walking, from rest in the re- 
cumbent position. A feeling as if one must walk and "could walk forever" 
is a-good general indication for this drug in diseases attended with pain. 

Hyperidrosis. — Sweating of neck, palms or soles, sour and glutinous, 
worse evenings, etc. 

Fragilitas crinium. — Hair tangled, distended veins of scalp, or sense of 
outward pressure, worse in occiput or parietal regions, with other symptoms of 
fluoric acid. 

Alopecia prematura. — Hair line recedes unusually from the temples, thin 
over the parietals; fullness in the head without itching brings a desire to 
scratch. 

Alopecia areata. — Bald patches confined to the left parietal region or worse 
on left side: feeling of pressure in temples or general fullness in head, worse 
when sitting or standing, etc. 

Dermatitis papillaris capillitii.— Fluoric acid is especially indicated in 
this disease on the tendency of scar tissue to become hypertrophic. 

Onychia or paronychia. — Deep-seated as if in bone, with throbbing pain; 
pain like splinter under the nail, worse at night and when held in a dependent 
position. 

Lupus vulgaris, L. erythematosus. — Hypertrophic growth of lupoid or 
cicatricial tissue therefrom. Deep bluish or purplish hyperemia and occa- 
sional or persistent painful sensations, worse from warmth and better from 
rapid motion. 

Cicatrix. — Scar formations attended with sensitiveness, unusual sensa- 
tions, venous hyperemia or overgrowth. Aggravations from warmth and fric- 
tion, temporary amelioration from motion. 

Keloid. — Sensitive, painful, purplish, or extending keloidal growths of all 
kinds; increase of hyperaemia and sensations from friction or warmth; relief 
from motion. 

Naevus pigmentosus. — All forms of acquired nsevi and congenital varieties 
which continue to increase in size, become changed or sensitive. Especially 
valuable for the aged or prematurely old. 



GRAPHITES 

Neuroma.— Fluoric acid may bo indicated in the early stages <>!' tins ran' 
affection by tenderness and pain in the growths being worse from warmth, 
better from cold and motion. 

Adenoma. — Benign adenoma (congenital or acquired) may be modified 
by fluoric acid when indicated by characteristic general or local symptoms, 
especially when associated with nam or varicose capillaries. 

The sixth decimal of fluoric acid is the best single attenuation. 



GRAPHITES 

This tissue drug so demoralizes nutrition, that while it diminishes the 
natural secretions of the skin, menstruation, etc., it induces pathological 
(catarrhal) secretions, inflammation and exudations in various s. It 

is useful, therefore, for persons who have inherited or acquired a preter- 
natural dryness of the skin, and who suffer from moist eruptions on Blight 
external irritation or injury. Graphites show a greater affinity for the 
side, for the epidermis and the glandular structures derived from it, sometimes 
extending to the subcutaneous tissue. When these tissues have been dest 
and replaced by cicatricial tissue, it is credited with effecting a restoration of 
the epithelium and great improvement in, or the disappearance of the scar. 
In functional affections of the glands of the skin it will often prove remedial. 

Beyond objective symptoms due to functional disorder, the most character- 
istic lesions produced are papules, vesicles and pustules. Concomitant ery- 
thema, resultant superficial ideerations, scaliness of the scalp and offensive 
crusts at the vertex are exceptional lesions which may suggest this drug. 
Sensations may vary in different cases quite widely ; itching, burning, smarting, 
sticking, crawling and rawness are the most common. These are aggravated 
by warmth, before menstruation, and by scratching. Temporary relief is often 
experienced by washing the parts or by rubbing. 

The location of conditions or eruptions calling for graphites are usually on 
those parts most abundantly supplied with glands and subject to effects of 
warmth or exposed to variations of temperature. Hence, the external genitals, 
feet, face, scalp, hands and arms are favorite sites; occasionally it is indicated 
for a generalized eruption papular (follicular) in kind. The general symp- 
toms of this drug may be important in any case. Among them the tendency to 
emaciation in early life, to obesity in late life, anaemia with redness of the face, 
tremulousness, drawing or throbbing through the whole body, general weak- 
ness, mental despondency and indecision are significant. 

Hyperidrosis or bromidrosis of feet. — Sweat of feet, worse after noon, 
evening and between toes; odor worse from walking; when other graphite 
symptoms correspond. 

Acne. — Skin unnaturally dry, sensitive, easily suppurates; in young wo- 
men inclined to grow stout when menstruation is diminished or delayed, and 
worse at this period. 



560 GRAPHITES 

Canities. — Hair turns gray from anaemia attended with periodic tendency 
to rush of blood to the head and semi-lateral headache; sad. despondent and 
inclined to weep. 

Folliculitis decalvans (alopecia follicularis). — Some of the varied forms 
of this disease are likely to present indications for graphites. Then it would 
probably lessen the formation of scar tissue and the consequent loss of hair. 

Onychauxis. — Nails become thick; sensations of contraction or constric- 
tion of fingers or toes, crawling in limbs; worse from warmth, better "from 
bathing or rubbing. 

Onychia. — Suppuration at the margins of great toe, pain in nail, pustules 
on little toe with sticking, exuberant granulations. 

Erythema traumaticum, Dermatitis traumatica, D. venenata. — When 
the sound skin is unusually dry and the local disturbance is excessive in pro- 
portion to the degree of injury or contact with a poisonous substance; with 
tendency of small wounds to suppurate; with burning, smarting, stinging, 
rawness or itching sensations, worse from warmth, pressure, scratching and 
exercise; better from washing or rubbing the affected parts. 

Eczema (subacute or chronic) is pathologically and symptomatically re- 
lated to the pathogenesis of graphites, particularly when vesiculation or a 
sticky exudation is the predominant condition. Vesicular or sero-purulent 
eczema of the scalp, ears, face or genitals, not infrequently presents indications 
for this drug. Swelling of neighboring lymphatic glands is sometimes a 
feature. It is especially adapted to moist eczema on and about the ears when 
the skin is not much thickened or heavily crusted, but cracks and bleeds easily. 
Similar types of the disease on the hands may suggest the drug, but more often 
on the hands and arms the skin is infiltrated, hard and fissured when graphites 
is indicated. It acts best when the dorsal surface is involved, but it has cured 
squamous eczema of the palms. Occasionally it is useful in eczema rubrum 
with apparently deep cracks, extending between the thick crusts to the raw 
surface beneath. In crusted eczema, especially at the vertex, the dried secre- 
tions decompose, if permitted to remain, and give rise to an odor, said to re- 
semble decayed herring. All forms of eczema indicating graphites are worse 
from warmth, itch more at night and the exudation is increased by scratching. 
Persistent dryness of portions of the skin unaffected with eczema is a special 
indication for this remedy. 

Herpes zoster. — Fully developed cases which persist with pruritic sensa- 
tions, worse from warmth, better from bathing parts, especially for left-sided 
zoster with large vesicles ; zoster following traumatism. 

Scleroderma. — Following exposure to cold and damp or in second stage; 
skin hard, tense-like cicatricial tissue, inclined to crack; dryness of whole sur- 
face, easily excoriated; bruised, stiff, drawing, cramp-like or rheumatic pains, 
numb or dead sensations ; in the obese with great shrinking of the affected parts, 
with general aggravations from warmth at menstrual periods, and relief from 
washing and rubbing parts. 

Morphcea, Atrophia maculosa et striata. — When apparently related to ex- 



HELLEBORUS NIGER-HEPAR BULPH1 H 581 

posures to cold and wet; spots, streaks or Lines resembling -car tissue; Left- 
sided, with general dryness of the skin. 

Tinea circinata, T. tonsurans. -When the unaffected skin is unusually 

dry. glands enlarged, sensations from the disease arc worse from warmth and 
better from washing, graphites will often assist m the cure by ini xeasing the 
normal resistance of the epidermis. 

Sycosis, Lupus vulgaris, Scrofuloderma. — Cicatricial Btage when 

formations tend to extend or disfigure. Graphites may be indicated by its 
affinity for glandular tissue and its apparent influence over the growth of new 
fibrous tissue, especially if other conditions and modalities suggest it as a 
remedy. 

Cicatrix, Keloid, Fibroma. — Scar tissue following traumatism or disease 
of the skin which tends to hypertrophy or to cause unusual disfigurement may 
be modified by graphites, especially if other conditions point to this remedy. 
It should always be considered as a possible remedy in the early stages of keloid 
or fibroma. 

Graphites may be administered in attenuations varying from the sixth to 
the twelfth decimal. Occasionally the high solutions are valuable in very 
typical cases. 

HELLEBORUS NIGER 

This drug in sufficient doses poisons the nerve centres, causes a semi- 
paralysis of the mental and physical powers, blunts all the senses, suspends or 
deranges nutrition and function, and deprives the system for a time of its 
inherent power of reaction. On the skin sudden swellings may appear, the 
surface desquamate, the hair and nails loosen and fall off without signs of 
inflammation. 

Alopecia generalis. — Hairs of whole body fall out without obvious cause 
other than atropho-neurotic. 

Atrophia unguis. — Nails fall out after painful sensations in fingers or 
toes, but with little or no signs of inflammation. 

Angioneurotic oedema. — Sudden swellings in skin of forehead or other 
regions associated with mental apathy or stupor and loss of vital reaction. 

The third decimal is a suitable attenuation for most cases. 



HEPAR SULPHUR (CALCIUM SULPHIDE) 

The impure sulphide of lime has a pathogenesis peculiar to itself and much 
wider than that of the chemically pure sulphide. The latter is to be preferred 
in only a few conditions, chiefly affecting the follicles of the skin, to be referred 
to in due order. This drug is ranked with the tissue sails, and has been found 
to act especially on the glandular system, the skin and connective tissue, cans- 



562 IJEPAR SULPHUR (CALCIUM SULPHIDE) 

ing a type of inflammation very liable to terminate in suppuration. The gen- 
eral disturbance of nutrition is manifested by easily excited perspiration, an 
extreme sensitiveness to open air, particularly to cold, dry winds and drafts of 
air; the local disturbance of nutrition is manifested by the great soreness and 
sensitiveness of the parts inflamed, simulating the sensations of lesions on the 
verge of suppuration. Sharp, pricking local pains often attend the morbid 
process set up by this drug ; in the head this sensation may amount to a press- 
ing or piercing, as though something had been driven into one side of the 
brain. Besides these characteristic sensations, almost any variety of pares- 
thesia may be experienced. Itching is often felt but is seldom pronounced. 
Burning tension (with swelling), throbbing, tickling, etc., are more common. 

The most characteristic lesion of hepar is the papule, prone to suppurate 
and often to extend the invasion by apparent infection and the outbreak of 
other discrete lesions in the surrounding tissues. The morbid process may 
extend into the deep glandular and subcutaneous tissue, and tubercles or abscess 
form, as in furuncles or carbuncles. The primary foci of inflammation may 
begin in a less circumscribed form than the papule, and extend by the pro- 
gressive involvement of contiguous skin, or by the advent of papules secondary 
in order of appearance. Whatever the onset, the latter method of extending 
the area of cutaneous eruptions is a characteristic of hepar. Distinct vesicula- 
tion is rarely a feature of this drug, and when observed the contents of the 
vesicles or blisters soon become purulent (often before rupture), and if the 
exudation continues it is sero-purulent in nature. 

Infiltration of the connective tissue may render the skin inelastic and liable 
to become fissured, especially on the hands and feet. If ulcers result from sup- 
puration, they are characterized by an abundant offensive discharge, by sensi- 
tiveness to touch, by bleeding easily, and by stinging, burning pains. 

The locations of hepar eruptions are commonly in regions where the glands 
of the skin are relatively numerous, or where the connective tissue is abundant 
or loosely attached. Hence the face, scalp, back of the neck, shoulders, flexures 
of the joints, nates, thighs and the genital region are favorite sites. Location 
is less important than other indications, and sometimes this is determined by 
an accidental injury or irritation, the wounded skin, as in the graphites condi- 
tion, being unable to institute the normal process of repair. 

Hyperidrosis. — Sweating on head, on perineum, worse at night; sensitive- 
ness of skin to slightest cold and to open air; sweat sometimes sour, sometimes 
offensive. 

Acne in youth to middle age. — Superficial and deep lesions nearly all sup- 
purate, attended with sharp pricking pains, sensitive to touch, bleed easily 
when rubbed or freely when incised ; new papules appear in or about the same 
area, swelling of neighboring glands, suppuration of all excoriations. (The 
pure sulphide is to be preferred for most cases indicating this drug, especially 
if symptoms are few.) 

Onychia and paronychia. — Swelling and tension of fingers. Clinically 



HEPAB SULPH1 K (CALCIUM BULPHID] 668 

hepar sulph. has been found very efficient in the cure of onychitis run-rounds 
and felons, where there is great sensitiveness and sharp pricking or suppurative 

pains. 

Erythema caloricum, Dermatitis calorica (chilblains, frost bite). — 
With a tendency of the redness or inflammation to spread to the adjacenl -kin; 
great soreness or sensitiveness of the parts and sharp pricking pains, worse 
from touch and cold, and better from warmth. 

Dermatitis traumatica, D. venenata.— Willi sharp suppurative pains and 
tendency to spread from slight causes; greai sensitiveness to and aggravations 
from cold air and from touch. 

In eczema hepar sulphur will be found useful when the exudation is Bero- 
purulent and offensive, the lesions are sensitive to touch and bleed when 
cleansed or rubbed, especially when they have originated from slight irrita- 
tions or injury and spread by papules or papulo-pustules appearing near the 
border. The scalp, ears, face and between the thighs arc the most common 
locations, but occasionally they may be observed in the flexures of the joints or 
elsewhere on the extremities. It is of special value in "occupation eczema" of 
the back of the hands and wrists when the parts are very sensitive and lend to 
suppurate; here the tendency of "slight injuries to suppurate** may find its 
greatest expression. Another type of eczema sometimes presenting indications 
for hepar is found on the palms of the hands: the skin becomes thick and 
inelastic from infiltration into, instead of an exudate on the surface, exfolia- 
tion in large or small scales occurs, fissures form, the parts become extremely 
sore to touch and pressure, and bleed if the partly detached scales are forcibly 
removed. 

Rarely a generalized follicular eczema is seen with discrete papulo-pustular 
lesions, for which the pure sulphide of calcium is better suited than hepar. 
Otherwise, the indications are the same. 

In all forms of eczema requiring this remedy, the sensations (burning, prick- 
ing, itching, etc.) are worse at night and often on rising in the morning. Great 
sensitiveness to cold and aggravations therefrom are important indications. 

Dermatitis repens from its origin, from injury, and sometimes from its 
course, may suggest hepar sulphur, especially when there is unusual sensitive- 
ness to cold, to touch, and red macules or papules appear ahead of the advanc- 
ing border. The writer has verified these indications in one case which had 
resisted other drugs and methods of treatment. 

Urticaria. — Great sensitiveness of the lesions, with sharp pricking pains 
as if about to suppurate, with sensitiveness to cold air or drafts ; in persistent 
or chronic cases. 

Herpes progenitalis. — With sharp pains, great soreness, offensive odor and 
tendency to spread and simulate superficial ulceration ; associated with fre- 
quent sweating of the genitals. 

Pompholyx. — Burning, tingling and soreness of parts, when lesions coal- 
esce and sharp suppurative sensations are felt, especially when new lesions 
continue toappear near by. become excoriated and bleed easily. 



564 HYDRASTIS 

Sycosis, Furuncles, Carbuncle. — Attended with much soreness, sensitive- 
ness to touch, pricking or burning pains, offensive or excoriating discharge, 
tendency for diseased area to spread by new discrete lesions, general or local 
aggravations from cold and relief from warmth. 

Actinomycosis with marked suppuration, soreness and sensitiveness, to the 
air. Located on the face or hands. 

Syphilis. — Pustular or suppurating lesions of the secondary or tertiary 
stage, unusually sensitive to touch, with offensive secretions; ulceration of the 
mucous membranes, thickened border and spongy base. After unsuccessful 
use of mercury. 

Paget's disease. — Early stage, well-defined lesion, copious exudation, at- 
tended with soreness, pricking or burning sensations. Local or general sensi- 
tiveness to .cold and to drafts of air. 

When the totality of the symptoms is classical hepar acts promptly in a 
high^attenuation, but for most cases met with in practice the second or third 
decimal is most effective. 

HYDRASTIS 

Hydrastis is essentially a catarrhal drug with a distinct affinity for the 
mucous membranes. On the skin its action is less direct or distinct, and is 
adapted rather to secondary, unusual or inactive types of disease, due to 
lowered vitality or constitutional impairment and made apparent by a pale or 
yellowish skin, functional or organic affections of the glands, cachexia, etc. 
The early lesions are commonly macular, papular or pustular. The first two 
may be inflammatory in nature or more like the development of new elements 
in the surface tissues. 

The most characteristic sensations are unbearable burning, itching and ten- 
sion ; worse at night, from change from cold to warm air, and usually relieved 
by scratching or friction. The favorite locations are the face, scalp, neck, 
hands, arms and the genital region. 

Clinically, hydrastis has been found adapted especially to inflammatory 
affections, sluggish or persistent in course, situated on the forehead at the 
margin of the hair ; or to degenerative or malignant diseases attended with its 
characteristic sensations. 

Bromidrosis. — Offensive sweat on the scrotum, worse at night with dis- 
turbing dreams, etc. 

Seborrhoeic dermatitis. — Worse at the margin of the hair on forehead 
and temples, persistent and attended with burning, itching or tension, relieved 
by cleansing or rubbing ; also of the scrotum, with similar indications and the 
general conditions pointing to hydrastis. 

Eczema at the junction of the hair-line on the forehead, beginning as 
macules or papules and passing into an indolent but irritated oozing patch 
or patches, and attended with the constitutional and local indications for 



BYDROt'O'n Li: vsi VI ic,\ 

hydrastis, has been cured with this drug. Eczema of the scrotum or pudenda 
excited by offensive perspiration occasional!) presents indications for hydrastis. 

Lupus erythematosus.— Beginning j„ u 1( . sebaceous glands of the 
neck, head or hands. Burning, itching or tension relieved by friction. Pale or 
yellowish complexion. 

Epithelioma (Rodent ulcer), Paget's disease.-- Severe burning sensa- 
tions, worse at night and from warmth. Early weakness, prostration, faintnea 
and cachexia, Especially for malignant ulcerations originating at the muco- 
cutaneous outlets or from a seborrhceic patch. 

Hydrastis is occasionally indicated in carcinoma of the skin by burning 
sensations, deficient nutrition, paleness, etc., foreshadowing early cachexia. 

The first to third decimal attenuations are best suited for treatment of cuta- 
neous diseases. 

HYCROCOTYLE ASIATICA 

The modus operandi of the action of this drug on the organism is not well 
known. While it stimulates the sweat glands and induces functional disorder 
of these parts, superficial inflammation and disturbances of sensations (hyper- 
esthesia, anaesthesia, paresthesia), it is useful therapeutically more often for 
conditions which might follow from continued stimulation of the superficial 
layers of the skin, namely, hypertrophy, exfoliation or other changes of the 
epidermis. 

General symptoms indicating this drug are weariness, heaviness, vertigo, 
unsteadiness, bruised sensations in the muscles, and mental gloominess, one or 
more causing unfitness for all effort. 



& 



Miliaria (sudamina) on abdomen from copious sweating, especially when 
general symptoms indicate hydrocotyle. 

Miliaria rubra. — Miliary papules and erythema on neck, back, chest and 
neck from excessive heat and perspiration with prickling, itching, crawling, 
constrictive or bruised sensations. 

Psoriasis inveterata, especially if the lesions become annular, circinate or 
gyrate in shape, and are located on the trunk as well as on the extremities, may 
suggest this remedy, even in the absence of other symptoms. The unusual loca- 
tion of this disease on the palms or soles with greatly increased thickness and 
exfoliation of the epidermis may indicate this drug. It has proved useful in 
psoriasis of the nails. Keratosis palmaris et plantaris, or involvement of 
the soles only, may present objective indications for hydrocotyle, and if the 
general symptoms correspond it is likely to prove curative. The sensations of 
numbness or constriction in the parts involved have been found good ind na- 
tions. 

Eczema rarely- presents indications for this drug. Chronic squamous 
eczema of long duration, found in circumscribed patches, attended with 
abundant or persistent desquamation and moderate subjective sensations in 



566 HYOSCYAMUS 

the lesions, is the only type likely to respond to this remedy unless the general 
symptoms are also very characteristic. 

Scleroderma. — Preceded or attended with sweating, pains in joints, con- 
tractions in arms and legs, weariness, heaviness and bruised sensations in 
affected parts, with thickening and rough, scaly epidermic patches here and 
there, or yellowish or brownish pigmentations. 

Pruritus vaginae. — Associated with local perspiration, heat in the vagina 
or vesical irritation, mental depression and physical weariness. 

Elephantiasis. — Eecurring erysipelas like redness of the skin, with in- 
creasing enlargement, pigmentation, exfoliation, roughness or unevenness of 
the surface. General weariness, unsteadiness and mental apathy. 

Lupus erythematosus, L. vulgaris. — Attended with considerable infiltra- 
tion or hypertrophy and sensations of numbness or constriction in the parts 
involved. Sometimes useful in the ulcerating forms of lupus vulgaris. 

^Leprosy. — Yellowish or reddish macular or tubercular lesions, with vari- 
able degree of hyperaesthesia or anaesthesia in different portions of affected 
skin. Ulcerating tubercles, especially about mucous outlets, with itching of 
affected or other parts of mucous membrane or skin. Mental and physical 
lassitude. 

Lymphangioma, Lymphangiectasis. — When associated with more or less 
hypertrophy of the lesions and adjacent skin or the seat of recurrent erysipela- 
tous inflammation may be benefited by hydrocotyle, particularly when the gen- 
eral indications for this remedy are present. 

Attenuations from the third to the sixth decimal are most often employed 
for the more pronounced diseases of the skin. 



HYOSCYAMUS 

This drug exerts a toxic effect on the cerebro-spinal centres, causing senso- 
mental perversions, irregular muscular contraction or relaxation, especially of 
the blood-vessels, and consequent hyperaemias, with little or no tendency to in- 
flammation, but sometimes ending in gangrene when the skin is involved. 

Besides erythematous and gangrenous lesions of the skin, associated 
papular-like swellings, bullae, and after the gangrenous slough separates, a 
bloody looking surface resembling ulcers may be seen. The erythema is more 
or less general but worse on the face, neck and extremities, attended with con- 
siderable swelling, sometimes closing the eyes, and also accompanied with red- 
ness of the mucous membrane of the mouth and throat. Parts of the affected 
skin may be dry like parchment, but exfoliation is not a marked feature. Sen- 
sations of stiffness, prickling, numbness, itching and bursting may be felt, and 
are usually worse from heat, touch, motion, after eating, and better from firm 
pressure, rubbing and from smoking. 

Erythema scarlatiniforme. — In neurotic (hypochondriacal, hysterical) 



in perici \i 567 

subjects or alcoholics, attended with muscular twitching*, excitement, and 

desire to strip oil' the clothing; looking like inflamed skm unh swelling, some- 
times becoming slum, purplish an.l very dry, with various pruritic sensations, 
worse in a warm room, from exercise, touch, an.l alter eating or drinking, and 
better from linn pressure and from smoking (when accustomed to tobacco) ; 
with redness of the throat as in scarlatina. 

Hysterical gangrene. — General dryness of the skin, diminished sensa- 
tion and marked mental symptoms; when gangrenous slough leaves bloody and 
painful ulcers, especially when associated with muscular twitchings and a 
desire to uncover the body. 

This drug needs to be given usually in a low attenuation, second or third 
decimal. 

HYPERICUM 

The pathogenesis of this drug is closely related to neurotic conditions, espe- 
cially of the peripheral nerves. Hence, in the cutaneous sphere it is sometimes 
a remedy for neurotic affections or for affections of parts richly supplied with 
nerves, especially if originating from injury. In an etiological sense it is re- 
lated to arnica, graphites and hepar sulphur. In a general way, it is adapted 
to cutaneous disorders in which the local subjective sensations are excessive in 
comparison with the number and extent of the lesions. The latter sometimes 
appear or disappear rapidly, and seem to be influenced by temporary changes 
in the density of the skin from alterations in the weather. 

The secretions of the skin may be increased or diminished, or papules, 
wheals and occasionally vesicles form. The favorite locations of lesions are the 
hands, face or over the branches of superficial nerves. The sensations attend- 
ing the onset and course of the eruptions are always pronounced, and may con- 
sist of itching, biting, sticking, fuzziness, crawling, tingling, or a sharp neu- 
ralgic pain. Symptoms are usually worse through the morning, and better at 
night and from pressure. 

Hyperidrosis. — Sweating of the scalp, worse in the morning after sleep, 
in damp weather, when preceded by some injury, however slight, heat and 
bursting pain in the head (vertex). 

Alopecia. — Falling of the hair from injury to central or peripheral nerve 
tissue or from excessive sweating of the scalp, with soreness, fuzziness, creeping 
or other paresthetic sensation in the scalp. 

Atrophia unguis, onychauxis, spoon or other trophic changes of the nails, 
when traceable to injury of the nerves of the extremities, may be benefited by 
hypericum. Indicated by sticking in fingers or toes, swollen, suppurating, 
biting, sticking, cutting or tearing sensations in fingers or thumbs. 

Erythema intertrigo, E. traumaticum, Dermatitis traumatica. — When 
any of the above sensations are excessively severe and are worse mornings and 
from friction, bettor nights and from uniform pressure: when the effed of 



568 IRIS VERSICOLOR 

injury extends on the line of peripheral nerves, or rises and falls with the 
aggravations and ameliorations of sensations. 

Eczema of the hands and face, with moderate primary eruption, intense 
itching, and which, from scratching, may give rise secondarily to bright red- 
ness, or to sero-purulent exudation and crusting, particularly if there is a 
history of previous injury of the part or of other parts, occasionally calls for 
this drug. In some cases there appears to be an abundant eruption in or under 
the skin, which does not readily break out but itches persistently; in others 
there may be only dryness of the skin, violent itching and later eczematous 
eruptions or exudation. The symptoms are usually worse through the morning 
and from friction, and are letter at night and from pressure. 

Urticaria. — When sensory disturbances are most marked in the morning; 
eruption worse on back of hands and between the fingers. 

Herpes zoster. — Vesicles beginning with sore places and forming hard, 
yellow crusts, attended with severe smarting, sticking and occasional sharp neu- 
ralgic pains; crawling or other paresthetic sensations extending to median 
line as eruption subsides. 

The hypericum has little effect on the skin, above the third decimal attenu- 
ation, and most cases require the first. In painful affections local applications 
of the tincture in equal parts of alcohol and distilled water will often give 
marked relief. 

IRIS VERSICOLOR 

This is another drug with distinctly neurotic properties, but, so far as the 
skin is concerned, the effects produced are chiefly reflex or secondary in order. 
The pathogenesis indicates that its primary action is on the gastro-intestinal 
tract and pancreas, while secondary effects may be manifested by hepatic de- 
rangements, nervous depression, neuralgic headache (migraine), pustular erup- 
tions of the face, scalp, etc. 

The cutaneous lesions may rest on a red base, the inflammation may tend to 
spread deeply or broadly (in lines), to suppurate slowly and rarely become fun- 
goid about the edges. The favorite locations for eruptions are the face, scalp 
(vertex), hands and wrists, but when the other symptoms of iris are distinct, 
the region involved is less important and even the form of the lesion need not 
contra-indicate this remedy. Sensations of soreness, tenderness (to touch), 
itching, and tension are most common. These are made worse by warmth, 
exercise and pressure. 

Pustular eczema of the scalp occurring in children, a similar form on 
the bearded portion of the face of adults, or at any age on the hands and 
wrists, giving a history of frequent gastro-intestinal and bilious attacks of 
headaches, or accompanied by such indications for iris, may be speedily cured 
by this drug. 

Generalized psoriasis, with irregular lesions, a scaly and irritated surface 



JABOBANDI— JUOLAN8 < l\i.i:i \ 

with elevated edges, giving a history of the gastro-intestinal or other symptoms 
of iris, have been cured with this remedy, li is probable thai such 
very rare. 

Herpes zoster.— Right-sided ; small vesicles on a red base, which broaden 
into wide lines of eruption, preceded or attended with gastric derangements or 
other characteristics of the drug. 

Dermatitis herpetiformis, Impetigo herpetiformis.— •Pin-head-sized 
icles changing into pustules, forming patches which crust in the centre, with 
local and constitutional disturbances similar to the pathogenesis oi iris. 

Iris versicolor sometimes acts better in the higher than in the lower attenu- 
ations. A good starter is the twelfth decimal, from which a higher or lower 
may be chosen, according to the effect or lack of action noted. 



JABORANDI 

This drug stimulates all the physiological secretions, and especially the 
perspiration, to an extreme degree. It sometimes stimulates the growth of 
hair, causes flushing of the face with throbbing in the temples, with anxiety, 
confusion, restlessness, palpitation or faintness. 

Hyperidrosis. — Profuse perspiration, with flushing of the face, mental 
confusion or anxiety, palpitation, etc., at the climacteric period in women; oc- 
casionally with similar symptoms in men in middle or later life. 

Jaborandi probably needs to be given in low attenuation (second decimal) 
in all cases. 

JUGLANS CINEREA 

The butternut, or its active principle, juglandin, acting on the vaso-motor 
and sensory nerves produces erythematous redness of the skin, papules, nodules, 
and sometimes pustular lesions. These are attended with sensations of burn- 
ing, pricking, itching, similar in some ways to several eruptive diseases believed 
to arise from the temporary presence of some toxic element in the system. 
Sensations are usually worse from getting heated, active exercise, and some 
relief is usually experienced from scratching. 

Erythema scarlatiniforme. — Exanthematous eruption, resembling flush 
of scarlatina, with chilliness, alternating with Hashes of heat : with itching, 
burning or pricking sensations, worse from getting heated and from active 
exercise, better or changed in type by scratching. 

Erythema nodosum. — Before nodules appear when sharp rheumatic or 
sprain-like pains are felt in the arms and legs, with chilliness without coldness 
of the surface, and flashes of heat ; with burning, pricking or itching sensations, 
worse from getting over warm; especially when attended with occipital head- 
ache. 



570 JUGLANS REGIA— KALIUM (POTASSIUM) SALTS 

An acute or subacute eczema may originate in like manner, appearing first 
as an erythematous or finely papular eruption, to remain such, or from greater 
local intensity pass into the vesicular or pustular stage. Itching may be felt 
apart from the eruption here and there; it is worse from getting heated and 
from active exercise, and is relieved in or about the lesions by scratching or 
changed to burning sensation. 

Medium attenuations are employed. 



JUGLANS REGIA 

While the action of this drug is somewhat like that of juglans cinerea, on 
the skin it seems to have a more distinct affinity for glandular structures. It 
gives rise to local perspiration, and to vesicular, papular, tubercular and pus- 
tular lesions. The chief locations are the face, hands, neck, shoulders, back, 
axillae and chest. Sensations are not important — itching, burning or painful 
soreness may occur. 

Hydradenitis suppurativa. — It is indicated by location of eruption in 
axilla?, on face, neck, etc.; connected with disturbance of coil glands (sweat- 
ing), absence of much sensory disturbance, and leaving some staining behind. 

Comedo. — Clinically found useful for comedones which appear to excite a 
folliculitis. 

Acne. — Papules and pustules on face, shoulders and chest, especially in 
persons subject to occipital headache or women with too early and blackish 
menstrual flow. 

Juglans regia should be given in the third to sixth decimal. 



KALIUM (POTASSIUM) SALTS 

Kalium does not occur free in nature, but some of its various salts are 
widely diffused in the organic and inorganic world. One or more of these salts 
are found in many vegetables, and in animals they are found more abundantly 
in those fed on vegetables. The potash salts are essential to animal health and 
the chloride is a normal constituent of the blood globules, the muscle cells, 
urine, and other secretions. It is probable that the other potassium salts are 
largely transformed in the animal system into the chloride. 

In a general way it may be said that the effect of these salts on animal tis- 
sues is to promote oxidation without causing fever when given in small doses ; 
while in large doses, notwithstanding the elimination is rapid, oxidation is im- 
paired, temperature reduced, the functions deranged, the blood deteriorated, 
nutrition disturbed or diminished, and an asthenic condition gradually estab- 
lished, from which recovery is slow. Thus remedial doses of the kalium salts 
are in a general way adapted to the cure of disease when the system seems in- 



KALI BICHR0MIC1 \i -.7 1 

capable (for the time being) of initiating the process of resolution or repair, 
especially when chiefly affecting the mucous membranes, the skin, the glandular 
structures, and the fibrous tissue. The influence of the potash base is some- 
times overshadowed by the action of the element combined with it, but its 
presence is apparent in the pathogenesis of all its compounds. 



KALI BICHROMICUM 

The chromic acid in this drug largely dominates its action. In small d 
this salt increases the secretions, in larger doses it is a tissue irritanl causing 
congestion, disorganization, and sometimes destruction of the parts. 

On the skin macules, papules, pustules, and ulcers are the mosi character- 
istic lesions; tubercles may form and pass into a purulent stage. Suppurating 
lesions are usually rather deeply situated and sharply cut at the edges. The 
crusts are often dry and more or less adherent. Location is not characteristic, 
though the face, scalp, or extremities are more commonly involved. Local 
sensations may be complex and consist of various degrees of burning, itching, 
tearing, etc., or there may be almost a total absence of abnormal sensations. 
When present they are commonly worse from pressure, in the hot weather, in 
the morning; and are better in cold weather and towards night. 

Papular or pustular forms of chronic eczema are occasionally seen present- 
ing some characteristics of kali bichromicum, such as great persistency, dry, 
adherent scales or crusts, burning and itching sensations worse in the morning 
and in hot weather. Secondary eczema from hepatic, kidney, catarrhal or 
rheumatic affections with indications for this drug have been cured with it as 
the primary disease also improved. 

Psoriasis with lesions more or less covered with firmly adherent scales, and 
which burn or smart after the scales fall off or when removed, occasionally re- 
sponds to the action of this drug. 

Dermatitis gangrenosa infantum is one of the rarer affections character- 
ized by secondary ulcerative or gangrenous inflammation beneath the crusts 
formed from a primary exudation. Prostration and other indications for kali 
bichromicum have been noted in some cases. 

Tinea barbae, Impetigo contagiosa, Ecthyma. — Ring-worm of the beard, 
with involvement of the hair follicles and persistent in course. Also in im- 
petigo and ecthyma when recovery is slow and the ulcers of the latter an- 
unusually deep, sharply cut and covered with dry. adherent crusts. Aggrava- 
tion of sensations from pressure and from hot weather: Amelioration from 
cool weather. Especially when associated with hepatic, urinary, rheumatic or 
catarrhal conditions. 

Phagedena tropica. — Kali bichromicum should be considered in the treat- 
ment of this tropical affection as likely to assist in the cure. 

Lupus vulgaris, Ulcerating syphilides. — Superficial or deep, sharply out 



572 KALI BROMATUM 

ulcers; perforating ulcers of the mucous membrane; tenaceous and stringy 
character of secretions ; soreness to touch, sometimes sharp pricking sensations 
and deep bone pains; worse mornings, in hot weather, letter in cool weather 
and afternoons. 

Attenuations from the third to the twelfth decimal are most reliable. 



KALI BROMATUM 

The bromine in this salt gives character to its action, and is termed 
"bromism." Among the effects are diminished cutaneous sensibility and 
papulo-pustular lesions known as "bromic acne." Other lesions of less fre- 
quent occurrence are macules, papules, tubercles, nodules, ulcers, vegetations, 
crusts or scales, and rarely bullae. The cutaneous effects of this drug probably 
all-originate from its action on the spinal cord, and are in nature tropho- 
neurotic, deranging nutrition. 

The common location of eruption is in regions most abundantly supplied 
with glands, such as the scalp, face, shoulders, neck and extremities. Sensa- 
tion is unimportant, and is never in proportion to objective features. 

Seborrhceic dermatitis. — Indicated by epithelial crusts (scales) which 
dissolve in ether and when dry leave greasy stain, pale reddish skin beneath, 
red areola, associated with papular lesions (Seb. papulosa), absence of pruritic 
sensations, mental and physical dullness. 

Acne simplex or indurata. — Papules with or without comedones slowly 
becoming tubercles and pustules; worse on face (forehead and nose), back of 
shoulders, chest, on hairy parts, and often extending sparsely beyond usual 
limits. Pustules yellowish-white, larger ones after discharge leave nodules 
or pigmentation, on healing leave small round depressed scars, in persons 
with thick, greasy skin. 

Acne varioliformis. — Papulo-pustules, worse on upper part of forehead, 
scalp and nose; leave stains and scars. 

Folliculitis decalvans. — Pathologically indicated by the strong affinity 
of kali bromatum for the follicles containing hairs; papulo-pustular and 
tuberculo-pustular lesions, discrete or confluent, leaving scars. 

Conglomerate suppurative perifolliculitis. — Some of the rarer effects of 
bromide of potash on the skin are very similar to the lesions of this disease. 

Erythema nodosum, E. induratum. — Fever with appearance of erythema- 
tous nodules on legs, tender to touch ; color disappears on pressure ; with mod- 
erate sensations of stiffness, burning, heat or tingling, worse from pressure, 
moving, and on getting warm in bed at night. Subcutaneous indurations, 
beginning in calves and sometimes appearing in other regions, firm to touch, 
with redness of the surface; in scrofulous subjects with weak circulation, en- 
larged glands, etc. ; flat indurations with purplish redness and tending to break 
down and form ulcers. 



KAI.I CARB0NIC1 M 

Rosacea. — At any stage in subjects who are mentallj dull, Buffer from eon- 
gestive headaches, vertigo or spasmodic affections; diminished senaibilit 
affected parts or moderate sensations of stiffness, burning, tingling, heat; 

worse from pressure and on getting warm from exert 

Herpes zoster. — In protracted cases, when lesions fail to clear ap after 
the characteristic neuralgic pains have ceased, or when redness Bpreads and 
lesions threaten to ulcerate, with mental and physical inertia and genera] loss 
of sensibility. 

Dermatitis herpetiformis, Impetigo herpetiformis, Herpes gestationis. — 
When subjective symptoms are not severe and constitutional depression and 
lack of vitality are more apparent than usual, especially in the vesiculo-pus- 
tular types, when new lesions show a preference for hairy parts, constantly 
appear and pursue a slow course. 

Pemphigus vulgaris. — Only in cases exhibiting general symptoms of 
'^bromism," new lesions constantly appearing and slowly undergoing change 
without marked subjective feeling. 

Actinomycosis, Mycetoma, Mycosis fungoides, Verruga.— 'The patho- 
genesis of kali brom. indicates that it might be useful in the treatment of these 
rare and unusual types of disease. 

Sycosis, Furuncle, Carbuncle, Scrofuloderma. — Persistent in course with 
little or no pain, especially when the onset begins in the spring. 

Leprosy. — Anaesthetic or painless macular or superficial ulcerating lesions, 
stationary or extremely slow in course. Especially in premonitory or early 
eruptive stage attended with mental dullness, depression and general distur- 
bances of nutrition. 

As the susceptibility to bromide of potash varies widely in different indi- 
viduals, the attenuations vary also in their therapeutic value. The writer lias 
found the lower decimals of the most value, occasionally using small doses of 
the saturated solution in hopeful cases which did not yield readily to attenu- 
ations when the drug was well indicated. 



KALI CARBONICUM 

Anaemic weakness, sensitiveness to and dread of open air, sticking, burning 
or itching sensations, ivorse from motion and at 2 to 3 a.m., are some general 
characteristics in the pathogenesis of this salt always to be kept in mind in 
choosing it as a remedy. The surface conditions to which it is adapted are 
always dry unless artificially irritated, always chronic in course, and are some- 
times attended with pigmentary changes. 

Chronic eczema of the squamous or papular type, wherever located, occur- 
ring in the anaemic, attended with sticking, burning or itching sensations which 
are worse in the open air, is nearly always benefited by kali earb. If the re- 
gions involved are exposed to external irritations of various kinds, to blood 



574 KALI IODATUM 

pressure in dependent parts, or to imprisoned secretions (sweat, etc.), vesicles 
and pustules may arise. Thus in some cases of eczema of the legs, hands, 
breasts, face and about the ears we may find kali carb. indicated for vesicular 
or pustular lesions which have succeeded dry forms of eruption. 

Lichen planus occasionally presents some general indications for kali carb. 
besides the dry papular lesions and consequent pigmentation characteristic of 
this disease. Then this remedy may be thought of if the lesions itch intensely, 
and especially if minute vesicles appear after scratching or rubbing; or if 
aggravations follow from being in the open air, from bodily warmth produced 
by exercise, and relief is experienced from combined pressure and cold. 

Lichen scrofulosus, an exceedingly rare disease in America, always asso- 
ciated with enlarged glands and other signs of struma, and always beginning 
before puberty, has presented good indications for kali carb. in some of the 
cases described. No verifications have been reported. 

^avus, Tinea circinata, T. tonsurans, T. barbae, T. versicolor. — When 
the patches are dry and superficial and the skin is anaemic and sensitive to air, 
kali carb. will help to restore the tone of the skin and thus aid in cure. 

Kali carb. acts well in both low and high attenuations. If it fails in a high 
potency when well indicated, it should be given in a lower or low, for experi- 
ence teaches that.it only influences some cases in the latter preparation. 



KALI IODATUM 

In this salt the combining iodide largely dominates its action and brings 
it into relation with more active or more advanced types of inflammation, par- 
ticularly of the vascular and glandular structures, but also showing the effect 
of potash in general systemic depression, in the slow development and persist- 
ency of lesions. 

On the skin this drug has produced a great variety of lesions, erythematous 
and hemorrhagic macules, papules, pustules, wheals, vesicles, bullae, nodules 
and fungoid growths. These effects vary greatly with the individual, and are 
more often due to medium rather than to large doses. Even a minute dose may 
produce a marked effect on persons sensitive to the action of this drug. The 
most constant lesions are papules, papulo-pustules and rather transient vesi- 
cles situated on an intensely hyperaemic base. Papules and pustules occur 
most commonly on the face, back of the shoulders, chest and arms, where the 
small blood-vessels and sebaceous glands are abundant. Erythema may be 
generalized, but when accompanied with vesiculation the groins, scrotum, 
hands, arms, feet, legs and the face are the favorite sites. Sensations of stick- 
ing, burning, itching or soreness may be hardly noticeable or of an intense 
character. When present they are icorse in the evening and are sometimes 
relieved by scratching. 

Acne. — Shot-like papules on the face, shoulders or chest, with intensely 



KALI MURIATIC! \1 

hypersemic areola, becoming pustular lirsi ai the apex, some advancing until 
totally pustular and leaving scars; or deep nodular lesions, tntenaely red, ex- 
tremely slow in their involution, and painfull} sensitive 

Eczema of the beard (papulo-pustulan occurring in individuals showing 

some evidences of the scrofulous, syphilitic or unknown constitutional taint, 
such as adenopathy, anaemia or emaciation, often without any marked sub- 
jective sensations in the lesions, may be cured with kali iodide. It is also a 
remedy in some cases of eczema rubrum of the legs, arms, or groins when the 
serous exudation is so abundant that crusts cannot form, or is less free and 
evaporates so rapidly as to leave portions of the surface dry and glazed but also 
without crusts. In such conditions burning, sticking, and drawing sensations 
often annoy the patient. 

Like kali carb. this drug may also fill a place in the therapeutics of lichen 
scrofulosus. 

Purpura. — On anterior surface of legs, lesions varying in color accord- 
ing to duration, the oldest being darker than the new; in the emaciated who 
are subject to rheumatic attacks or rheumatoid pains, frontal headaches and 
debility. 

Dermatitis herpetiformis. — The polymorphous eruptions produced by 
kali iod. and attendant systemic depression should lead to its study in cases of 
this rare disease. 

Pemphigus vulgaris. — In severe cases with numerous lesions preceded by 
considerable redness and involving the mucous membranes, especially when 
situated on hands, arms, feet or groins, and associated with enlargement of the 
lymphatic glands. 

Syphilis. — Generalized or grouped. Shot-like papules, sometimes becom- 
ing pustular at the apex; macular, tubercular, nodular, bullous or ulcerating 
lesions of late secondary or tertiary period, which appear slowly and continue 
persistently with or without anaemia, loss of flesh, etc. Especially when erup- 
tion is most abundant on face and upper parts of trunk. 

Molluscum contagiosum. — Especially of the face or genitals, when the 
lesions do not tend to soften or disappear. 

Only lower attenuations are suited to the more pronounced affections of the 
skin, and frequently drop doses of the saturated solution are more homoeopathic 
and effective. 

KALI MURIATICUM 

This salt, containing one equivalent of kalium and chlorine, according to 
Schuessler, stands in chemical relation to normal and pathological conditions 
of the fibrous tissue, and in secondary conditions of the surface membranes 
when infiltrations occur into the connective, or outwardly into the epithelial 
tissues, it has proved of clinical value. It is adapted especially to the second 
stage of congestive or inflammatory affections, when there is a general aggrava- 
tion of symptoms from motion. 



576 KALI PHOSPHORICUM 

Seborrhoea sicca. — Whitish flour-like scales on scalp or face, in anaemic 
children, especially when appearing after vaccination. 

Acne. — Infiltrated papules on the face, which remain indolent or are 
transformed into pustules with whitish contents. Acne apparently con- 
nected with gastric or genital (menstrual) derangements; especially valua- 
ble in the early stages before other remedies and to prevent suppuration of 
papules. 

Onychia or paronychia. — Deep infiltration about the toe nail threatening 
suppuration. 

Erythema multiforme. — When vesicles or bullae form; in anaemic subjects 
who suffer from menstrual derangements ; in persistent cases when lesions dis- 
appear slowly and sensations are worse from motion. 

Dermatitis calorica. — Burns of all degrees to arrest progress of inflam- 
mation, especially of the second degree, when vesicles or bullae form or when 
resolution is delayed. Chilblains in young women afflicted with menstrual dis- 
orders and cold extremities; with sensations worse from motion; with a ten- 
dency to vesiculation or necrosis of the skin. 

Vaccination eruptions. — Vesicular and bullous eruptions which appear 
within three days after inoculation; erysipelatous, furuncular or gangrenous 
lesions, due to infection through the vaccine wound. 

Chronic eczema characterized by sero-purulent exudation or the formation 
of whitish crusts or scales, persistency in course, enlargement of the lymphatic 
glands, and general anaemia of the subject, will often yield to the action of this 
remedy. It is adapted rather for intercurrent than prolonged administration 
and is never suited to acute forms of eczema. The sixth decimal. 

Sycosis. — In early stage, pustules with whitish contents; later stage, dry, 
flour-like scales; associated with nasal catarrh; persistent in course, with 
glandular swellings and anaemia. 

Lupus vulgaris, L. erythematosus. — As an intercurrent remedy in cases 
largely involving the glands of the skin and not responding to indicated treat- 
ment. Grayish- white coating on the tongue. Gastro-intestinal symptoms. 
worse from fatty or rich food. 

Verruca. — Warts on hands (kali nitricum, face) which remain unchanged 
for months. 

The sixth decimal seems to be the most reliable attenuation. 



KALI PHOSPHORICUM 

This is another salt found in animal tissues and fluids, and is probably 
essential to the proper stability of nerve nutrition and function. Clinically it 
has been found useful in diseases involving the nervous system or in which the 
expression is largely neurotic. Symptoms or conditions are always worse when 
the patient is unoccupied, at rest or alone, and are better from agreeable occu- 
pation, company or exercise. Such patients are apt to exaggerate their symp- 



KALI BULPH1 RIC1 M 

toms, are abnormally sensitive to al] impressions, and often exhibil other effects 

of a low nervous tone. 

Dermatitis calorica.— Jiums of moderate extent or degree with exagger- 
ated sensations, much worse when the patienl is unoccupied, alone, or res 
or burns of like character which form offensive exudations and which, from 
contact, cause the adjacent sound skin to inflame. Chilblains of the bands, 
toes or ears in neurotic subjects, with excessive sensations of tingling, crawling 
or itching, worse when quiet, alone, or unoccupied. 

Vaccination eruptions. — For same conditions as kali mur., but occun 
in neurotic subjects who complain of severe painful sensations, always worse 
when alone, etc. 

Kali phos. is remedial in some forms of so-called neurotic eczemas in which 
the symptoms (sensations of itching, crawling, etc.) are always worse when the 
patient is unoccupied or alone, from tiresome exercise or long rest, and from 
hard scratching or rubbing; better from agreeable occupation, company or 
exercise, and from gentle friction. Such patients are apt to exaggerate their 
symptoms, are abnormally sensitive to all disagreeable impressions and often 
exhibit other evidences of a low nervous tone. The forms of eruptive lesions 
are not characteristic, but if exudations occur on the surface, they are likely 
to be irritating and offensive and in long lasting cases the skin generally may 
appear withered. 

Carbuncle, Anthrax. — Attended with exaggerated pain and other neurotic 
symptoms, relieved by agreeable occupation or company. 

Epithelioma, Carcinoma. — In inoperable or advanced cases, for relief of 
pains and offensive discharges. 

The third or sixth decimal attenuation is usually effective, but sometimes 
the second or even the first decimal may be none too low. 



KALI SULPHURICUM 

This salt is found normally in epithelial cells and the intervening fluids, 
and it has been found of value in the treatment of disease affecting the epider- 
mal structures, particularly in the retrograde stage of inflammatory affections. 
At the acme the exudations may be solid or fluid — yellowish, serous, or sero- 
purulent; at a later stage the primary or secondary lesions may have receded, 
leaving the surface harsh and dry, or moist and scaly. 

General symptoms of physical inaction from loss of vitality are usually con- 
comitant indications as in most of the kalium salts, but the neurotic symptoms 
of kali phos. are not present. 

Sensation or location is not especially characteristic, but all symptoms are 
usually worse in the evening and in a warm room, and arc better in the cool 
open air. 



578 KALMIA 

Seborrhoea sicca. — Abundant dry, whitish scales on the scalp; headache 
worse in a warm room and in the evening, better in open air; adapted to chronic 
cases or late stages of more acute cases of seborrhceic disorders. 

Alopecia prematura. — Symmetrical loss of hair from persistent seborrhoea 
(dandruff), scalp dry and harsh to touch, headache with characteristic modali- 
ties. May be used locally in aqueous dilution 1-100. 

Atrophia unguis. — Undeveloped nails from general defects of nutrition; 
shrunken or irregular nails left after inflammatory conditions subside. 

Eczema in an advanced stage occasionally presents modalities correspond- 
ing to those of kali sulph. The surface conditions may consist of a continuous 
oozing of a yellowish or greenish fluid secretion which can only dry into thin 
crusts before separation occurs from the persistently moist base beneath; or 
the eczematous surface may have passed into the squamous stage from which 
a rather abundant exfoliation of scales continues indefinitely, apparently from 
loss of power of the epidermis to regenerate normal cells. 

Favus, Tinea tonsurans, T. barbae, T. versicolor, erythrasma. — Super- 
ficial forms of favus or ringworm of the scalp or beard attended with abundant 
scales or exfoliation of the epidermis at the periphery as the disease spreads. 
In these and other fungus affections which are persistent the affected parts 
are harsh, dry or scaly; atrophic conditions therefrom. Local or general 
symptoms worse in the evening, in a warm room, and better in the cool, 
open air. 

Epithelioma. — Involving only epidermal tissue; a thin serous or sero- 
purulent discharge and thin crusts less adherent than usual in this disease. 

The sixth decimal is commonly the best dose, but occasionally needs to be 
discarded for a lower attenuation. 



KALMIA 

This drug acts especially on the sensory nerves, causing tingling, numbness, 
neuralgic pains, headaches, shifting in location or character and with or with- 
out signs of inflammation ; it slows and weakens the heart's action ; most symp- 
toms increase with the advance of day and diminish as night sets in. 

Hyperaesthesia of the skin or Dermatalgia. — When characterized by 
shifting, aggravations by day, relief at night, and especially when associated 
with a slow, weak pulse and oppression of breathing. 

Herpes zoster. — Sometimes in the pre-eruptive stage when tingling, prick- 
ing or neuralgic pains are worse by clay, from motion and the patient becomes 
weak, tremulous and easily exhausted. Especially valuable for neuralgic pains 
following the acme of herpes zoster, or persisting as the eruption subside?. 

Kalmia acts best, as a rule, in the second or third decimal attenuation. 



KRE080TUM 



KREOSOTUM 

Carbolic acid is the chief principle in (creosote, but there ia difference 
enough in their pathogenesis to give each a distinct place as a remedy. Bjpi 
disorganizes the blood, produces an irritant effect on the mucoua membranes 
and the skin, which may thus cause general or local disturbances of nutrition, 
derangement of function or inflammation of the surface tissues. Through its 
action on the nerve centres a great variety of paresthetic sensations may be felt 
in the peripheral nerves. 

On the skin it produces functional derangements of the sebaceous and sweat 
glands, a tendency to ecchymoses < from slight causes), papules, vesicles, fis- 
sures, scales and crusts, persistent and unhealthy in character, sometimes degen- 
erating into malignancy with offensive secretions, and rarely showing a gan- 
grenous tendency. Sensations indicating kreosote are more often described as 
burning, itching, biting, stiffness or tensive pain. The favorite location for 
papular and scaly eruptions are the back of the hands, the lace, ears, hack and 
shoulders; for fissures, the hands and on or about the lips; while vesicles or 
wheals may occur at these points of selection or generally over the surface. 
The eruptions arc worse, as a rule, at night in bed, from pressure of clothing, 
from friction, but may be relieved by scratching. 

Seborrheic dermatitis. — Papular and scaly lesions on the face, ears and 
shoulders, with "fatty" crusts, persistent in course, attended at intervals with 
burning, itching, etc. — worse at night and from friction, better in open air. 

Canities. — Hair very gray, with sensitiveness of scalp to slight traction 
on the hair or to touch; neuralgic, rheumatic or suppurative pain from shoul- 
ders to head or in the vertex, worse at night. 

Alopecia prematura. — Loss of hair from seborrhcea, with characteristic 
sensations and modalities. 

Papulo-squamous or papulo-vesicular eczema of the dorsal surface of the 
fingers and hands, sometimes excited by repeated contact with irritating sub- 
stances (trade eczemas) and obstinate in course, frequently present enough 
indications for kreosote to make it a curative remedy par excellence. Moist 
eczemas of the face or ears with offensive secretions, burning and itching pains, 
worse at night, may be cured with this drug. 

Dermatitis gangrenosa infantum. — In this affection the vomiting, diar- 
rhoea, emaciation, as well as the evolution and course of the cutaneous eruption, 
are somewhat similar to those credited to kreosote, and in other diseases have 
been verified by its use. 

Pruritus. — Of hands, arms or legs, worse at night, from rubbing, better in 
open air, sometimes from scratching or changed thereby to burning; pruritus 
vulva? after parturition or after menstruation, especially when latter discharge 
is offensive. 

Urticaria. — Generalized form with intense itching, changing to burning 



580 LACHESIS 

or scratching, relieved by exposure of skin to the air, worse from light rubbing 
or pressure. 

Diabetic gangrene, Hysterical gangrene. — Severe burning pain, soreness 
and offensive odor after menstruation or associated with genito-urinary dis- 
orders. 

Lupus vulgaris, Epithelioma, Carcinoma. — Ulcerating stage with offen- 
sive secretions, or in earlier stage of lesions at or near mucous outlets; espe- 
cially of the pudenda, with shooting, stitch-like, burning, biting or tense sensa- 
tions; worse at night and from pressure, better while in open air. Sallow 
complexion, great debility, sleeplessness and irritability. 

Kreosote should be given in the second to twelfth decimal attenuation ac- 
cording to the nature of the case or the susceptibility of the individual. 



LACHESIS 

This serpent poison acting on the cerebro-spinal nerve centres and the blood 
causes peculiar nervous phenomena, low, hemorrhagic or malignant types of 
inflammation, the effects of which appear to be always worse after sleep, with 
general and local sensitiveness sometimes exaggerated bej-ond the objective 
severity of the disease. Other disturbances of sensation may consist of any 
variety of pruritus, but burning and itching are the most common. All kinds 
of primary and secondary lesions have been recorded, characterized by a dark 
red, bluish or purplish color, great sensitiveness to touch and a tendency to be 
most abundant on the left side. 

Urticaria. — On face, back, shoulders or legs, especially when more numer- 
ous on left side; lesions are an unusual deep red color or hemorrhagic, Ten- 
sensitive to touch and first appearing after sleep. 

U. pigmentosa. — In cases which are hemorrhagic early show a marked 
preference for the face, neck and shoulders; the first or new crops show most 
after sleep and are sensitive to touch. 

Purpura, P. hemorrhagica. — Extremely sore feeling over whole body, 
bluish-black lesions which sometimes look gangrenous; hemorrhages from 
mucous surfaces of very dark blood, especially at climacteric period, associated 
with general prostration. 

Herpes zoster, hemorrhagic type. — Prevesicular redness, darker color 
than usual and vesicles become dark early, with burning pain and sensitiveness 
to even light contact especially for attacks in the spring or fall, with symptoms 
all worse after sleep. 

Dermatitis herpetiformis (Impetigo herpetiformis, Herpes gestationis). 
— In adynamic cases when lesions appear slowly, become darker in color and 
are attended with soreness or much tenderness, lachesis may be studied as a 
remedy for this rare affection. 

Pemphigus foliaceus, P. vegetans. — Partly filled blisters containing de- 



LEDUM &81 

composed or offensive serum; burning and Borenese of the skin; mental and 
physical prostration; at the climacteric period, with mosl symptoms worse 
after sleep. Pemphigus vegetans. Sure lesions become fungoid, dark red to 
brownish, or look like a ilat sponge with genera] indications Tor lachi 

Carbuncle. — Bluish or dark red. Left-aided Lesions; burning sensations, 
worse at night, from pressure on near parts and alter Bleep; carl \ adynamic 
symptoms as from blood poisoning. Carbuncles at the climacteric period or in 
fall or spring. 

Syphilis. — Papulo-pustular or ulcerating lesions with offensive discus 
deep red, bluish or purplish areola and unusually sensitive; sensitive ulcers 
of mouth or throat; aching in the bones, pains in the head and other symptoms 
worse at night and after sleep. 

Leprosy. — Yellowish, deep reddish-brown or livid hyperffisthetic sp 
nodes or swellings; gangrenous Looking, sensitive ulcers; hemorrhagic dis- 
charges from 1111100113 01111018. As a palliative when symptoms are worse alter 
sleep. 

Erysipelas. — Bluish-red, swollen, sensitive skin; aching through crown of 
head, vertigo and other persistent cerebral symptoms, worse after sleep; early 
prostration, faintness and cold extremities. Especially for Left-sided disease 
and pains. 

Paget's disease. — Appearing at climacteric period; deep red or purplish 
lesions, sensitive to pressure, with burning or cutting pains, worse at night and 
after sleep. In later incurable stages for pains which are relieved by a free 
bloody discharge. 

Mycosis fungoides, Verruga.— Laehesis may be indicated in those rare 
affections by slowly developing deep red, sensitive lesions, burning sensations 
and tendency to ulcerate, accompanied with constitutional symptoms and mo- 
dalities like this drug. 

The twelfth decimal attenuation is preferred for frequent or infrequent 
administrations as the case may require. 



LEDUM 

Ledum palustre has an affinity for the superficial fibrous tissue of the 
joints and blood-vessels, the mucous membrane and the skin. Its action on 
the smaller joints may simulate chronic gout, and the eruptions of the skin 
resemble those which are sometimes observed in the gout v. 

The most characteristic lesions are papules ; less so are small hemorrhagic 
macules, vesicles, pustules and furuncular abscess. The favorite Ion/lions are 
the face, forehead, inner side of the forearms, wrists, lingers and dorsal surface 
of the feet, or the eruption may be generalized over the covered portions of the 
skin. 

The sensations are characterized by their likeness to the sensations caused 
by the stings of insects and from other penetrating wounds, i.e.. biting, itching. 



582 LYCOPODIUM 

stinging, sticking and sensitiveness. Shifting of sensations, or the place of, 
is significant; and lack of bodily heat or coldness of the surface is a negative 
indication for ledum. Aggravations usually occur in the evening, from heat, 
especially from heat of bed, but do not last through the night. Scratching gives 
temporary relief, but is often followed by more intense itching, etc. 

Papular eczema occurring in the gouty or associated with gouty pains in 
the smaller joints, may be cured with ledum. Eczematous outbreaks occurring 
in persons suffering from an ill-defined dyscrasia. and representing similar 
sensations and modalities to this drug, may often be relieved from the cutaneous 
disease by its action. It is particularly adapted to chronic eczema of the face 
occurring in alcoholics. 

Lichen planus sometimes presents indications for ledum. The character- 
istic location of the eruption on the inner surface of the forearms and wrists 
corresponds pretty well with the bluish-red spots in the same location credited 
to this drug, and the sensations may be very like in character. 

Urticaria. — Stinging, biting sensations without increase of surface heat ; 
site of eruption or sensation of shifting, especially when associated with gout}' 
pains, and all symptoms are aggravated by warmth of bed. 

Prurigo. — Early stage, miliary papules following primary urticarial 
lesions ; generalized eruption on covered parts ; biting, stinging or itching sen- 
sations, worse from warmth of bed and only temporarily relieved by scratching. 

Insect bites, Boils. — Shifting, biting, stinging, itching or sore sensations, 
worse in evening, from warmth, and temporarily relieved by scratching. Espe- 
cially for gouty or intemperate subjects. 

Ledum may be given in the second to sixth decimal according to the effect 
obtained. 

LYCOPODIUM 

This substance properly prepared as a medicine and given in suitable doses 
acts on the mucous membranes, the organs connecting therewith and on the 
skin. It disturbs the functions of these parts and induces secondary debility 
and changes of tissue with characteristic manifestations, frequently resembling 
the uric acid diathesis. Some general indications are a desire for the open air, 
mental confusion and weakness, fullness in stomach after little food and con- 
stipation. 

It may cause only functional derangements and disturbances of nutrition of 
the skin, or nearly every form of primary lesion. Of these, pigmentary macules, 
inflammatory and non-inflammatory papules, vesicles and pustules are the 
most common ; while secondary scales, ulcers and crusts have been observed. 
The course of most eruptions shows the loss of vital resistance and lack of 
reparative power in the dermal tissues. 

Location is not very characteristic, but eruptions oftener occur where the 
skin is exposed, active or thick, as on the face, neck, hands, shoulders, thighs, 
etc., or where it folds on itself. 



LYC0P0DI1 m 

Sensations are varied; corrosive burning or itching, sticking, biting and 
soreness are the most common. The Bymptoms are usually worse from warmth, 
touch, on rising from bed, forenoons, and between 1 and 8 p. \i. They arc better 
in the open air, from rubbing and scratching, at noon, and alter 8 P.M. 

Anidrosis. — Dry, shrunken skin from lack of nutrition, in the emaciated 

or prematurely old. in those subject to uric acid disorders or attended with 
other characteristics of lycopodium. 

Asteatosis. — General dryness and roughness of the skin from constitutional 
states, especially when associated with the peculiar gastric symptoms of lyco- 
podium and signs of presenility (see anidrosis). 

Acne. — Papules beneath the skin of forehead at first without color ; .similar 
lesions or papulo-pustules on cheeks, chin, between shoulders, etc.; grayish- 
yellow color of the face with occasional sensations of heat, especially in the 
prematurely old with lycopodium symptoms elsewhere. 

Canities. — Hair becomes gray early, preceded or accompanied by dryness of 
the scalp, drawing or tensive sensations and some of the general indications 
of this drug. 

Alopecia. — Great falling of the hair of the scalp with a concurrent incn 
in growth in other hairy regions. Useful when indicated by other local (see 
canities, etc.) and general symptoms. 

Onychia. — Inflammation about the base of the nail, healed after discharged 
pus. In the rheumatic or gouty when other indications correspond. 

Lentigo, Chloasma. — Freckles worse on left side of face and on nose ; itch- 
ing liver spots ; in thin, debilitated young people who suffer from gastrointes- 
tinal, genito-urinary and other affections with symptoms indicating lycopo- 
dium. 

Erythema intertrigo, E. caloricum (chilblains). — Eedness between 
of skin with biirning, sticking or soreness, worse from warmth, forenoons, be- 
tween 4 and 8 p.m. ; chilblains on fingers with similar conditions and symptoms. 

Chronic eczema associated with urinary, gastric or hepatic affections, or 
dependent on a dyscrasia which originated from functional derangements, fre- 
quently calls for lycopodium, either as an intercurrent or longer continued 
remedy. Such eczemas usually begin as a papular erupt ion. which becomes 
vesicular or moist, bleeds easily, and behind the ears and in other folds of the 
skin assumes a raw condition with an offensive sero-purulent and irritating 
discharge. If situatedon or near the nose and lips, they may appear swollen. 
and in cases of long duration, the cervical glands may become swollen and 
tender. When the eruption begins at the back of the head or neck and extends 
forward this remedy is especially indicated. 

Psoriasis occasionally presents a few good indications for Lycopodium. 
either in the general symptoms or in connection with the functions of digestion, 
secretion or excretion. A dark red, almost raw appearance of the lesions, 
scanty scales easily bleeding on slight irritation, may BUggesi the use of this 
remedy when other symptoms are wanting. 



584 MANGANUM 

Favus, Tinea tonsurans. — Beginning at several points with marked ten- 
dency to irritate the scalp; abundant crusts or scales; fetid or offensive odor; 
pruritic sensations, worse from warmth, better in open air. 

Impetigo contagiosa. — Persistent cases; offensive odor; heat of room or 
bed excites scratching; in prematurely old children; relief of all subjective 
symptoms in the open air. 

Furuncle, Carbuncle. — Any location when occurring in the prematurely 
old, gouty or rheumatic, with aggravations of pain from hot applications, be- 
tween 4 and 8 p.m., better during the night. Following excessive use of alco- 
holic stimulants; periodic boils. 

Phagedena tropica. — Lycopodium might prove curative when the disease 
starts at site of a small scratch; in subjects suffering from malnutrition, de- 
bility, with local or general aggravations from warmth and moisture. Full 
feeling in stomach from little food, desire for open air. 

^-I<upus vulgaris, Syphilis. — Recent ulcerations without tendency to heal 
under treatment and apparently due to nervous or systemic depression ; hunger 
with satiety which prevents sufficient food being taken; ulcers of the mucous 
membranes (especially right-sided) of grayish-yellow color. General aggra- 
vations from warmth, on rising, between 4 and 8 p.m. ; relief from cold and in 
open air. 

Naevus pigmentosus, N. vasculosus. — With hypertrophy or elevation of 
the surface and tendency to enlarge in size; in the prematurely old with re- 
laxed or wrinkled skin, loss of mental and bodily vigor, fullness in the stomach 
from little food; constipation, uric acid diathesis with general modalities of 
lycopodium. 

Fibroma, Verruca. — Large isolated, painless, sessile or pedunculated wart 
or tumor-like growths; general dryness of the skin and signs of premature 
age with mental weakness or confusion and general lack of proper nutrition. 
In suitable cases warts will disappear under changed nutrition from the influ- 
ence of this drug and fibromata may cease to multiply. 

The medicinal value of lycopodium depends on its preparation, therefore 
it should be seldom prescribed below the twelfth decimal. Often indeed a 
higher attenuation seems to act with greater promptness. 



MANGANUM 

The salts of manganum (acetate, carbonate, chloride and oxide) are believed 
to produce their effects through the blood like ferrum. They cause fullness in 
the head, derangements of menstruation, motor paralysis, papular and vesicular 
eruptions of the skin, and a great variety of paresthetic sensations. Manga- 
nese is only adapted to the treatment of chronic cutaneous disease. 

In chronic eczema associated with amenorrhcea, aggravated at the men- 
strual period or occurring at the menopause, this drug will sometimes afford 



MEBCURIU8 (MEBC1 RIUB \l\ I 

relief when the more common remedies fail. The pruritic sensations an- well 
marked, though variable in quality, ami an- temporarily relieved by prec 

and scratching. 

Bare cases oi' psoriasis"in females, first appearing about puberty with some 

menstrual irregularity, or recurring at the menopause, may he relieved by 
remedial doses of manganese. The small papules tapped with scales produced 
by this drug are very like the primary lesions of psoriasis. 

Lichen planus, a chronic disease which probably arises from malnutrition 
of the nervous system, sometimes affecting the generative functions, is char- 
acterized by lesions, location and sensations similar to those found in the patho- 
genesis of manganese. Cases of lichen have been palliated by this remedy, ami 
it will probably be found curative in others. 

Pruritus. — Itching, biting, etc.. sensations here and there, chiefly below the 
knees, usually worse from changes of the weather; relieved temporarily by 
scratching, especially at critical periods of life in anaemic subjects, with Bense 
of fullness in the head. 

Prurigo. — Anaemic subjects, especially girls who suffer from menstrua] 
irregularities, and eruption of pruritic sensations are worse at approach of 
menses and from weather changes. 

Attenuations from the third to the twelfth decimal mav he used. 



MERCURIUS (MERCURIUS VIVUS) 

Mercury acts primarily on the blood, producing a sort of fatty degeneration 
with a marked reduction in the number of its corpuscles and in the quantity of 
its fibrin and albumen. A veritable haematic anaemia and cachexia result ; the 
functions of the body are deranged, and with saturation of the system destruc- 
tive inflammation may attack almost any organ or tissue. The pathogeneses 
of all the mercurial preparations are very similar, though the chlorides, cyan- 
ides, iodides and sulphides are largely influenced by the action of the combining 
element in each salt respectively. 

Some general indications for mercurius are weariness, prostration, trem- 
bling of voluntary muscles (tongue, hands, etc.), deep boring pains, offensive 
(foul) odor of the secretions and glandular swellings. Special indications are. 
aggravations at night, from warmth of bed, during perspiration or exercise, and 
from wet and cold; amelioration from rest and during the day. 

On the skin mercury has produced nearly every form of primary and 
ondary lesion observed in cutaneous disease. The more characteristic are 
macules, papules, vesicles, ulcers, scales and crusts. Location is not ('specially 
characteristic; the more common sites of selection are the head, face, flexor and 
inner surfaces of the extremities and the genital region. Sensations may van- 
widely from an intense itching, burning or neuralgic pain to the milder sense 
of tension or swelling. 



586 MERCURIUS (MERCURIUS VIVUS) 

Chromidrosis. — Sweat leaving yellowish stains, oily at night, on soles, on 
palms, on fingers, which look spongy and wrinkled. 

Miliaria. — Sudamina on abdomen, chest and arms ; discrete vesicles, either 
transparent or translucent (on abdomen) ; eruption preceded by pruritus and 
followed by desquamation ; from excessive sweating due to systemic debility or 
violent exercise. 

Seborrhceic dermatitis. — Oily perspiration, sharply defined red macules 
on abdomen, inner surface of arms and thighs, genitals, chest or scalp fol- 
lowed in a few days by desquamation, leaving surface red or pigmented ; burn- 
ing or itching, worse at night, from exercise, wet and cold weather ; in anaemic 
individuals the process tends to repeat its course before resolution from the 
previous one is complete. 

Alopecia. — Falling of hair after acute or subacute seborrhceic affections, 
from constrictive headaches, worse at night and painful to touch; syphilitic 
alopecia, worse at occiput. 

Atrophia unguis. — Exfoliation of nails, in cachectic anaemia, with other 
mercurius symptoms, or following non-specific affections of the nails under like 
systemic conditions. 

Erythema intertrigo. — Eedness between thighs and genitals, with intense 
burning, soreness or rawness, worse at night, from perspiration, warmth of 
bed, in wet and cold weather, better from rest and during the day ; with swell- 
ing of neighboring glands. 

Erythema multiforme. — Erythematous spots on trunk and anterior aspect 
of extremities ; in circles which later run together ; light red, scarlet, bluish-red, 
darkest at margins ; with itching changed to burning by scratching : symptoms 
worse from warmth of bed, at night, better during day. 

Eczema of the papular, vesicular or purulent type occurring in the anaemic 
or cachectic, who have a pale or sallow appearance of the unaffected skin in 
contrast with an intense redness of the affected parts, will often present other 
indications for mercurius. Eczema intertrigo beginning as an erythema, on 
which vesicles form and produce a weeping surface, the intensely reddened skin 
extending continuous with or in patches beyond the line of contact of the 
opposing surfaces, frequently calls for this drug. The exudation may become 
sero-purulent, offensive and parts of the affected area may appear like super- 
ficial ulcers, or look raw and angry (eczema rubrum). It is sometimes indi- 
cated in papular eczema beginning on the flexor surface of the joints of the 
elbows and knees and tending to merge together to form thickened, scaly 
patches. 

Pustular eczema in children occurring on the scalp and face, encircled 
with intensely red areolae may suggest this remedy. In such eczemas the pru- 
ritic sensations are worse from exercise, perspiration and at night: better from 
rest and during the day. Sometimes scratching gives relief, or again it may 
cause bleeding and painful smarting of the parts. The lymphatic glands often 
swell in chronic cases. 

Psoriasis of recent origin, especially when located on the back of the hands, 



MERCURIUS BINI0DID1 - 587 

forearms, scalp, thighs, chesl or abdomen, and the lesions beneath the scales 

arc a dark or brownish-red color, may be relieved or cured with mercury if 
general or other special indications for this remedy are present. It is often 
of service for psoriasis of the finger nails. 

A rare inflammation of the skin described as dermatitis repens presents 
some resemblance to the superficial serpiginou- ulceration of the skin attributed 
to mercury. 

In the early stage of lichen planus of the skin, and of the mucous mem- 
brane of the mouth, in debilitated subjects mercury is sometimes indicated. 
The location on the wrists, forearms, abdomen and thighs of bluish-red, scaly 
or shiny papules, the aggravated itching at night, from heat, from undressing, 
etc., may be counted as good indications for this remedy. 

Scabies, Sycosis, Erythema. — Sensitive or painful, rapidly formed pus- 
tules or suppurative lesions with acrid or offensive secretions and deep red 
areola; debilitated or cachectic subjects: itching, burning or tension, worse 
from exercise, warmth of bed, at night; some relief from rest and during the 
day. 

Syphilis. — See article on. 

Leprosy. — Ulcerating and other destructive processes, especially of fad' 
and mouth, with odor of decomposition and general or local aggravations at 
night, from extremes of temperature, and relief during the day. 

Mercurius virus may be administered in the third to the twelfth decimal 
attenuation. 

MERCURIUS BINIODIDUS 

The iodine in this drug predominates over the mercury in action and in the 
cutaneous sphere determines the affinity for the glandular structures, while the 
symptoms are more likely to resemble those of the latter. It produces discrete 
papulo-pustules, crusted lesions from under which the pus may ooze, chiefly 
located on the hairy parts and attended with sensations of pricking and itching. 

Eczema of the hair follicles (E. folliculorum), sometimes remaining papu- 
lar and scaly, sometimes becoming pustular and capped with crusts, located on 
the scalp, other hairy parts or at the anus, attended with a variable decree of 
itching, pricking or soreness, and especially if accompanied with swelling of 
the neighboring lymphatic glands, may often be cured with mercurius binic- 
dide. It is indicated in fissured eczema of the anus and for eczema of the 
umbilicus which originates from follicular inflammation. 

Tinea barbae, Sycosis. — Papules, tubercles or nodules, becoming pustular, 
with considerable infiltration; oozing of purulent or muco-purulenl tluid: 
pricking, sore or itching sensations often worse from warmth and at night: 
glandular swellings; depression and irritability. 

Ecthyma. — Pustules passing rapidly into superficial ulcers with hard base, 
dark red areola and crusts from which pus oozes: sore and pricking sensations, 
worse at night, better in open air. 



588 MERCURIUS CORROSIVUS— MEZEREUM 

Yaws. — Papules, tubercles and growths which tend to soften and ulcerate, 
with constitutional symptoms similar to those produced by iodine and mercury. 

The second and third decimal attenuations are suitable for most of the 
above affections. 

MERCURIUS CORROSIVUS 

The bichloride of mercury is a corrosive irritant poison to animal tissues, 
much more violent in action than mercury alone, with a special affinity for the 
mucous and serous membranes. On the skin it gives rise to harshness, dark red 
erythema, small, dusky papules, to vesicles or bullae, sensations of itching, 
burning, etc., with aggravations and ameliorations similar to mercurius vivus. 

Lichen ruber at some stage of its course may present cutaneous symptoms 
similar to this mercurial, and it is quite possible that it might share in a meas- 
ure with arsenic as a remedy in curable cases of this disease. In lichen planus 
mercurius cor. should be compared with other drugs in selecting a remedy. 

Ecthyma. — Originating from papular or vesicular lesions; dark, dry 
crusts humid at the circumference ; sticking, burning pains, worse from warmth 
of bed. 

Syphilis. — See article on. 

Paget's disease, Epithelioma. — Painful glandular swelling about nipple 
or dusky patches with sticking or burning pains ; spreading, uneven, irregular 
ulcers which bleed easily and discharge thin bloody or acrid fluid ; severe shoot- 
ing, lancinating pains, worse at night, from warmth and not relieved by cold. 

The sixth decimal is a good average attenuation for use in skin diseases. 



MEZEREUM 

This drug acts specifically on the skin, the bones, and in a less specific way 
on the mucous membranes, producing irritation, neuralgic pains, and various 
stages or types of inflammation. 

On the skin it first causes pruritic sensations particularly of parts least 
cushioned by fat beneath. If the irritation set up is continued erythema, pap- 
ules, scales, vesicles or pustules appear. The latter become covered with thick 
crusts underneath which the purulent exudation goes on and adds to their 
thickness, or oozes out at the sides and excoriates contiguous surfaces; or 
scratching may cause bleeding and inoculate new parts. The secretion of 
sebum may be increased, rendering the exudations more or less fatty in char- 
acter. Distinct vesiculation is not a common effect of mezereum, but serum 
may form underneath the horny layer of the epidermis, producing a more or 
less extensive exfoliation of the latter. When ulcers form they secrete a puru- 
lent, adhesive fluid, are surrounded by a dark red areola, and they bleed easily 
on removal of the crusts. 



MEZERE1 M 

The locutions on which the more characteristic effects of the drug have been 
observed are the scalp, behind the ears, the face, wrists, hands, arms, chest, 

thighs and legs, but the distribution may be general and is likely to be worse 
on one side of the body. The sensations are usually pronounced and conaisl 
chiefly of intolerable itching, crawling and sticking, which may be changed to 
burning or gnawing by scratching. Twitching and other varied sensations may 
commingle or supplant those named. 

Aggravations occur at night, from warmth, scratching, contad and in the 
damp weather. Amelioration is felt in the open air, while walking (though 
there may be sensitiveness to cold air). Sensations of chilliness may be felt 
with the more intense pruritus. 

Seborrhea sicca. — Dry scurf on scalp; crust looks chalky and extends to 
brows and nape; hair inclined to bristle; itching, worse from warmth at aighi 
in bed, converted into burning when scratched, leaves brownish stain when 
healed. 

Eczema of the pustular or purulent type is most likely to correspond to the 
pathogenesis of mezereum. Such forms may occur on the face, scalp, behind 
the ears, or on the hands in infancy or childhood. Often the little patients 
scratch or rub the parts until they bleed, to be followed by a more abundant 
purulent discharge and crusting if the latter are permitted to form. On the 
scalp the hair may become matted with the dried exudation, and if neglected, 
the imprisoned secretions beneath (and sometimes pediculi) contribute to a 
most offensive condition to sight and smell. The intense pruritic sensations 
are worse at night and from heat; better in the open air and sometimes from 
scratching. 

In adults a mezereum type of eczema may occur on the back of one hand 
or wrist (usually the left), or more rarely on other regions. In such cases the 
irritating discharges may cause vesicles to appear at the border of the lesions 
or patches. 

Psoriasis may rarely exhibit indications for mezereum. The dark red 
patches on the head, arms, chest, thighs, back, or more generally distributed 
and incompletely covered with round, dry, whitish scales are sufficiently like 
psoriasis, provided the subjective sensations also correspond. Itching, burning, 
etc., of the lesions, worse at night, from warmth, and which bleed easily on 
scratching are good indications, likewise associated chilliness. Psoriasis of 
the palms with some of these indications has been cured with this remedy. 

Pityriasis rubra, a very rare disease, has sensations of chilliness, burning, 
itching, tingling, etc., with more or less exfoliation of the epidermis something 
like the effect of this drug. It should be considered in the therapeutics of a case. 

Pityriasis rosea may resemble the mild effects of mezereum. The chilli- 
ness and the nightly aggravations of itching, when present, are especially char- 
acteristic. 

Pruritus. — Of old people and in lean regions of the body. Etching or 
crawling sensations, irorsr at nighl from heat, scratching (sometimes changed 



590 MURIATICUM ACIDUM 

to burning), better in the open air and temporarily from stimulants; when 
associated or alternating with gastric disorders attended with burning pains 
or with neuralgic attacks. 

Herpes zoster. — Of intercostal region chiefly, when lesions tend to sup- 
purate, with burning sensation from pressure or friction, worse at night from 
heat, damp weather, better from cool air. When neuralgic pains continue after 
eruption begins to subside or has cleared up. 

Favus, Tinea tonsurans. — Unilateral distribution of one or more scaly 
lesions, attended with marked pruritus, worse from warmth and from scratch- 
ing or changed in character by the latter. Sometimes associated with eczema- 
tous inflammation with thick crusts under which pus collects. 

Syphilis. — Secondary or tertiary eruptions more abundant on one side, 
attended at times with sensory disturbances in the skin, bruised and wean- 
feelings in the joints, aching in the shafts of bones; periostitis or nodes of 
superficial bones; ulcers, sensitive, easily bleed on removal of crusts; elevated 
whitish crusts (rupial syphilide) ; persistent secondary affections of the throat 
with redness of affected parts and hoarseness; intermittent chilliness with 
varied conditions ; special or general aggravations at night, in damp weather, 
from local warmth, and relief from open air. 

Scrofuloderma. — One-sided deep ulceration with thick whitish-yellow 
crusts and oozing of yellowish exudation; or papulo-pustular lesions limited 
to or worse on one side; all lesions subject at times to unusual disturbances of 
sensation with some modalities characteristic of mezereum. 

This drug can be used in a wide range of attenuations. The sixth decimal 
is a reliable dose, but cures have been reported from the higher attenuations up 
to the two hundredth. 

MURIATICUM ACIDUM 

In proper doses this acid is capable of modifying (through the blood) the 
functions of the mucous membranes and the skin so that the secretions become 
foul, inflammations easily arise, and sometimes an asthenic fever develops. 

The skin lesions may be papular, vesicular, pustular or ulcerative. These 
are commonly located in the neighborhood of the mucous outlets or on the ex- 
tremities. Itching, smarting and burning are the most common sensations. 
but their absence should not be counted against the drug. The pruritic sensa- 
tions are usually worse while at rest, from warmth and touch ; better from 
scratching and rubbing. Some general indications for this remedy are weak- 
ness, irritability, vertigo on walking, cachexia, and in chronic conditions swell- 
ing of the cervical glands. 

In cachectic eczema muriatic acid may be an important remedy when con- 
comitant states of the mucous membrane exist. Unhealthy secretions, irrita- 
tion, aphthous or iilcerative spots of the mucous lining of the mouth are always 
good indications for it. in an associated papular, vesicular or crusted eczema 



NATR1 \i (80DI1 M SALTS •>' , 1 

about the nostrils, mouth or on the other parta of the face, eara or neck when 
the general and BpeciaJ symptoms correspond. Ii will be found useful in 
eczema between the thighs, excited In cohtacl of irritating perspiration, urine, 

urethral discharges or feces in amende children or adults when benzoic or nunc 
acid fails. Eczema rubrum of the Legs sometimes presents good indications 

for this medicine and is cured by its action. It is to be remembered as an 
occasional remedy for eczema ani, especiall) when accessory to hemorrhoids. 

Lichen scrofulosorum attended with intercurrenl eczematous outbn 
ulcerative dermatitis, with adenopathy and other signs of strumous cachexia 
would probably yield in a measure, if not wholly, to the action of muriatic acid. 

Ecthyma. — In weak, scorbutic or cachectic subjects; foul Bmelling ulcers 
or crusts on the lower extremities, with burning sensations at margins, nurs, 
from warmth; associated with affections of the mucous membrane of mouth 
or throat. 

Carbuncle. — When intercurrent with scorbutic conditions or anaemia due 
to previous disease, with offensive (putrid) odor of secretions from mucous 
membranes, with or without ulcerations thereof; burning sensations especially 
at circumference, worse from warmth. 

Epithelioma. — Involving the mucous membrane at some outlet of tin- 
body; base of ulcer grayish-white, edges of a bluish-red color, accompanied 
with smarting or burning sensations; with general asthenia and periods of 
great prostration. 

Muriatic acid should be always given in aqueous solution and in a low 
attenuation, third to sixth decimal attenuation. 



NATRUM (SODIUM) SALTS 

The soda salts act especially on the vegetative functions of the system, im- 
pairing the quality of the blood and the various secretion-, thus deranging the 
processes of nutrition and in time inducing dyscrasise which simulate a variety 
of diseases. Certain symptoms, such as vertigo, headache, palpitation, faint- 
ness and weariness, are quite common; periodicity is often a feature, and symp- 
toms in general are belter in dry and warm weather and worse in cool and wet 
weather. 

In the cutaneous sphere there may appear localized sweating, especially of 
the hands and feet; localized and abnormal activity of the sebaceous glands 
manifested by fatty secretions. The same or other parts may at times become 
dry, harsh and over-sensitive to touch; or pigmentary and erythematous 
macules, papules, vesicles, nodules, pustules, scales, crusts and warty u r rowth< 
may develop. The hair may become thin and the parotid and lymphatic 
glands painful and swollen. 



592 NATRUM ARSEN1CATUM— NATRUM MURIATICUM 



NATRUM ARSENICATUM 

In this drug the action of the sodium is only modified by the arsenic. The 
most characteristic lesions of the skin are pigmentary macules on the face, 
miliary papules on the face and neck, and red, scaly patches over the sternum. 
Sensations of itching and burning are aggravated by warmth, from exercise or 
the bed, from washing, scratching, and from allowing scales to accumulate on 
the patches. 

Seborrhceic dermatitis. — Miliary papules on face and neck (seborrhcea 
papulosa) ; irregular reddish-yellow patches on face ; reddish scaly patches on 
chest; itching or burning under accumulated scales, worse from warmth in 
bed or from exercise, washing, scratching and when scales re-form. 

^Chloasma. — Yellowish, with patches on cheeks and forehead; in the 
cachectic who have lost much in weight; in sufferers from chronic catarrh of 
nose or throat or from pulmonary disease. 

In psoriasis, especially on the anterior chest or lower part of the back. 
When itching is felt from the presence of the scales, from warmth, and the 
lesions become a darker red after removal of scales natrum ars. is to be con- 
sidered as a remedjr. 

Lichen rubra has been favorably affected by this salt. 

Pityriasis rosea is characterized by circumscribed pinkish, yellowish or 
reddish scaly patches, which itch, as a rule, worse at night — sufficiently like 
the scaly lesions attributed to natrum ars. as to suggest it as a medicine proba- 
bly adapted to some cases. 

Tinea versicolor. — Brownish scaly spots chiefly on or near sternal region 
of trunk; pruritic sensation from warmth of clothing or exercise. Helps re- 
store normal resistance of the skin. 

Syphilis.— Secondary macular, miliary, papular or scaly syphilide most 
abundant on chest, neck or face. Absence of pruritic sensations or only ex- 
cited by bodily warmth, bathing or from presence of scales. Valuable as an 
intercurrent or alternate remedy in cachectic stage, with swelling of lymphatic 
glands. 

This drug will be found effective in suitable cases in the third to sixth 
decimal attenuation. 

NATRUM MURIATICUM 

This is the most important of the natrum salts and includes in its action on 
the skin all the essential pathogenesis of natrum carbonicum. Associated gen- 
eral conditions are important. Some of these are emaciation, especially of the 
trunk, mental excitement, irritability or indifference, throbbing headache, 
vertigo and physical weakness. More common lesions of the skin are papules, 
vesicles, pustules, scales, crusts, fissures and superficial ulcers. More char- 



NATRUM MIKIATIUM 

acteristic locations are the back of the neck ;it margin o£ hair, back of m n, 
face, flexor surfaces of knees, elbows, outer pan of arms and legs, genital 
region, hands, feet and scalp. Often there is a tendency for Leaii isume 

a circular or segment of a circular outline. 8eruatiom may be pronounced or 
consist of soreness, itching, sticking, biting, Bmarting or burning. These are 
usually worse forenoons, after tea, at night, in the open air and from bathing 
the parts. 

Hyperidrosis. — Sweating on hands or head, worse at night, or perio. lie- 
sweating of other parts at night, in scorbutic, anaemic and emaciated indi- 
viduals. 

Seborrhceic dermatitis. — Greasy skin, papular, gritty and scaly lesions on 
or about the margin of scalp, face, extremities and genital region, with sore- 
ness, smarting, etc., worse morning and night, from bathing, or exposing cov- 
ered parts to air; debility, periodic complaints. 

Alopecia prematura. — Falling of hair from general lack of nutrition and 
local seborrhceic disorders, musty odor from scalp, itching, tension and sensi- 
tiveness of scalp; especially with characteristic headache, worse from talking, 
reading, lying down; better from pressure. 

Falling of hair of beard, and mons veneris, with general symptoms of 
natrum mur. 

Onychia. — Inflammation of sides, root and beneath nails, with suppurative 
sticking pain and tension; from eczema or other diathetic disease with other 
indications for this remedy. 

Erythema multiforme. — Circular lesions, with tendency of eruption t<> 
spread over body; like a bruise on back of hands; preceded and attended with 
fever, thirst and headache characteristic of nat. mur. ; with sensations of burn- 
ing, sticking, biting,, itching or soreness, worse forenoons, at night, in open 
air, from taking tea and from bathing the pari-. 

Eczema occurring in the cachectic (scorbutic), subacute and intercurrent, 
or chronic and persistent, may develop symptoms similar to those of nat nun 
mur. In the subacute form it is usually vesicular with oozing of a corrosive 
fluid, and located about the hair line on the posterior surface of the neck, back 
of the ears, in the flexures of the extremities, on the arms, or on the genital.-. 
Chronic forms of eczema may follow the acute or subacute, the skin become 
infiltrated, deep red and more or less covered with crusts. Deep lissmvs may 
appear, bleed easily or discharge a bloody serum. Such cases may continue 
indefinitely (better and worse) or pass into the squamous form. Other dry 
eczemas calling for natrum may originate from erythematous or papular 
lesions, which may remain discrete or merge together to form larger scaly 
patches. The latter type occurs on the back of the hands ami often attacks 
one or more of the nails, which become dry at the angles of attachment ami 
irregular in shape. Follicular (papular) eczema of the extremities occasion- 
ally requires this remedy. It is also indicated in some cases of pustular or 
squamous eczema of the scalp attended with thinning of the hair. In severe 



594 NATRUM MURIATICUM 

cases of eczema the lymphatic glands are found swollen in some degree. In 
the foregoing forms of this disease natrum mur. is curative when indicated by 
its general characteristics and modalities, which should be carefully studied. 

Lichen planus may be accompanied with some general symptoms indicat- 
ing natrum mur. Then the small and large papules on the arms, thighs and 
abdomen credited to this drug would supply the corresponding surface indica- 
tions in cases attended with pruritis. 

Keratosis pilaris in lithsemic children and young adults has been helped 
with natrum carb., and natrum mur. has been found indicated and curative in 
keratosis palmaris et plantaris. 

Pruritus, P. vulvae. — Periodic type, most frequent in late autumn, some- 
times malarial in origin; pruritic sensations vary in quality and degree, but 
more commonly occur in cold and wet weather, worse morning and night, after 
drinking tea, and are relieved somewhat by rubbing and walking about. 
Prwritus vulvce with dry, sore feeling in vagina, backache, bearing down in 
pelvis, relieved by sitting or lying down, especially with menstrual derange- 
ments or subinvolution of uterus and general cachectic debility. 

Urticaria, U. pigmentosa. — Persistent or periodic type, worse on arms 
and hands, color increased by rubbing; intense itching in early morning or 
late at night, especially when associated with malarial disease. Urticaria pig- 
mentosa associated with a scorbutic or malarial cachexia ; tendency to circular 
grouping of lesions and a periodic increase of pigmentation. 

Purpura hemorrhagica. — Few lesions of the skin of dependent parts 
(hands, legs, scrotum), with bleeding from mucous outlets, associated with 
great weakness, vertigo, relieved by lying down; spongy gums, dry mouth, 
mapped tongue, thirst; marked periodicity in attacks or symptoms of one 
attack. 

Herpes. — Associated with periodic fever, of mucous outlets and adjacent 
skin; grouped vesicles with acid contents, red areola, attended with pricking 
and itching sensations, worse from pressure and warmth. 

Dermatitis herpetiformis (Herpes gestationis, Impetigo herpetiformis). 
— Periodic or intermittent outbreaks of vesicular, ervthematous, pustular, etc., 
lesions which tend to assume a circinate arrangement, irregularity in distribu- 
tion and development, attended with intense pricking, itching or burning sen- 
sations, preceded or accompanied with febrile and other constitutional disturb- 
ances, may all call to mind similar phenomena in the pathogenesis of natrum 
mur. It ought to be of special value when the subject is suffering from jjelvic 
disorders, is debilitated or cachectic, and sensations are worse at night, from 
bathing, etc. 

Favus, Tinea tonsurans. — Musty odor from the scalp ; round or circular 
scaly patches on occiput near the margin of the hair or about the nails : thin 
and anamxic children; pruritic sensations, worse after washing parts. 

Furuncle. — On the genital region or the neck near hair line with a ten- 
dency to group in segment of a circle; periodic outbreak of boils: smarting, 
burning, sore or sticking sensations, worse morning and night and from wash- 
ing; in the debilitated from malaria, scorbutus, etc. 



NATRI M PHOSPHORII UM 595 

Lupus vulgaris, L. erythematosus. Dry. nodular, circular or r ided 

lesions or patches situated on fare, neck or extensor surface of extremities 
associated with some of the general characteristics of natrum muriaticum. 

Syphilis. — As an intercurreni remedj when eruptions arc persistenl in 
anaemia or cachectic Btage; sore, dry mouth; gums easily Meed, map-like 
appearance of tongue, weakness and sinking in stomach ; Bcalj fissured patches; 
moist lesions about amis, scaly and wart-like Lesions on palms or Boles; emacia- 
tion, especially about neck; aggravations at night, forenoons, after bathing or 
general periodic aggravations every few da vs. 

Verruca, Clavus. — Following excessive use of salt or aggravated by Hying 
al seashore; on palms or soles and persistenl without apparent cause; large 
and sensitive warts or corns. 

Natrum mux. only develops its medicinal virtues by attenuation, therefore 
it should not be given in the lower preparations. The sixth decimal to the 
two-hundredth centesimal have proved effective in skin affections. The twelfth 
decimal is perhaps the best single preparation. 



NATRUM PHOSPHORICUM 

This sodium salt, according to Schuessler. stands in relation to the produc- 
tion of an excess of lactic acid in the system, and is curative in some affections 
associated with hyperacidity. This condition is said to be indicated by a moist, 
creamy or golden yellow coating on the buck of the Unique and soft palate, acid 
or coppery taste, sour stomach, sour smelling sweat, mental anxiety and appro- 
hensiveness, etc. Symptoms generally are worse during a thunderstorm, dur- 
ing the menstrual period and in the afternoon and evening. 

On the skin pronounced itching, biting or burning sensations may be fell at 
first without eruptions or with a sparse outbreak of erythemato-papular, nod- 
ular or vesicular lesions, aggravated especially by rubbing after going to bed. 

Erythema intertrigo. — With sour smelling perspiration or exudation and 
characteristic tongue, etc. ; especially when seated in shallow folds of skin about 
the anus, with rawness or other sensations, worse after retiring to bed. 

Erythema multiforme. — Papular and nodular lesions on broad erythema- 
tous base, worse on lumbar region, buttocks and thighs; eruption like insect 
bites increased by rubbing, with chilliness and Hashes of heat, acid sweats. 
mental anxiety and apprehension. 

Pruritus.— In early life (childhood or youth), when characteristic symp- 
toms of hyperacidity are present; pruritic sensations in folds of skin, worse 
at night in bed; of young women at the menstrual period. 

Urticaria. — Generalized papular and nodular lesions like inseel bites, 
worse on lumbar region, buttocks and thighs: biting, itching or burning -< nsar 
tions, worse from rubbing; with chilliness and Hashes of heat, acid Bweats, 



596 NATRUM SULPHURICUM— NITRUM ACIDUM 

mental anxiety and apprehensiveness ; attacks during a thunderstorm or at the 
menstrual period. 

The sixth decimal is to be preferred for use in most cases. 



NATRUM SULPHURICUM 

This salt is said to be present in the intercellular fluids and to determine 
largely the excretion of water from the system. It has been found adapted to 
complaints associated with the so-called hydrogenoid proclivities of the system, 
always worse from damp weather or from living in damp houses or places, 
generally from lying on left side, from motion, and in the evening; better from 
being in the open air. In skin affections it is indicated more by conditions 
than by lesions. 

Hyperidrosis. — Sweat on scrotum when sitting, yellowish sweat; sweat on 
head preceded by vertigo, from habitual exposure to dampness, when there is 
pufnness of the skin and symptoms of sodium and sulphur. 

Onychia or paronychia. — Burning, sticking, or ulcerative pain behind and 
under nails; tearing, pulsating pains in tips of fingers: better out of doors. 

Pompholyx. — Vesicular lesions imbedded in sides of palms or fingers or 
hands, in subjects habitually exposed to dampness. Weariness, vertigo, palpi- 
tation, etc., generally relieved while in the open air. 

Pemphigus. — Few lesions on extremities; after long exposure to damp- 
ness; in debilitated subjects with symptoms worse in damp weather and better 
in the dry. open air. 

Impetigo contagiosa. — Lesions filled with yellowish fluid, which dry into 
yellowish crusts; children who live in basements or damp rooms; greenish- 
brown coating on back of tongue. 

Sycosis. — Very yellow pustules and crusts; in the debilitated who have 
been habitually exposed to dampness or with local or general symptoms worse 
in damp weather. 

Verruca. — Warts on head, trunk or about anus which first appeared after 
long or frequent exposure to dampness, or after gastro-hepatic disorder at- 
tended with greenish-gray or brown coated tongue and aggravations from lying 
on left side. 

The third to sixth decimals are suitable attenuations for the above diseases. 



NITRUM ACIDUM 

Nitric acid disturbs the functions, inflames and disorganizes the tissues, 
especially of the mucous membrane and the skin, and induces dyscrasia simu- 
lating the conditions sometimes observed from syphilis, scrofula or from the 
action of mercurjr. Mental irritability, excitement, depression, emaciation and 



NITRUM ACID1 \i Mfl 

physical weakness are general symptoms. In the skin ii may give rise to 
abnormal secretions or almost every primary and secondary lesion. .Men- 
characteristic are pigmentary macules, papules vesicles, pustules, ulcer-, fis- 
sures, crusts and warty or fungoid growths. The favorite Locations are al or 
about the muco-cutaneous outlets or on the face, neck, hand-., Lingers and 
trunk. Sensations are characteristic, such as sticking (splinter-like), stinging, 
pricking, itching, burning heat, sensitiveness ami tension, and may be Felt in 
or about the lesions. These may be mild in character, though often Bevere : they 
are worse, as a rule, from touch, uncovering, getting wret, at night, on rising, 
and are sometimes belter from gentle rubbing, bathing and from warmth. 

Nitric acid acts best on the dark complexioned and those who have reached 
or passed middle life. 

Hyperidrosis. — Sweating on soles causing soreness of toes and balls of feet, 

at night or every other night with sticking sensations; sweating of palms, 
hands cold, nails blue; relief from gentle friction and warmth. 

Bromidrosis or uridrosis. — Offensive sweat in axillae at night: sweat with 
odor of horses' urine. 

Seborrheic dermatitis. — Crusts scales and rawness, especially about 
mouth, nose, arms, and vulva with sticking, pricking or burning sensations, 
irorse at night, from touch, washing and on rising. 

Comedo. — Black pores on face, with scaly surface, sticking, burning salta- 
tions and other symptoms of nitric acid. 

Acne simplex and indurata. — Papules on face (worse on forehead near 
hair line and on chin), with hyperemia or pigmentary areola : small and large 
pustules which become indurated, especially on chin, neck and shoulder-; 
painful to touch, with sticking sensations until pus forms at apex ; in brunettes 
who are depressed and irritable but easily excited. 

Alopecia prematura. — Falling of hair after humid or scaly eruptions, or 
with nocturnal Headache deep in bones with baud-like tension; relieved by 
tight pressure and warmth. Falling of hair from pubic region. 

Lentigo, Chloasma. — Dark freckles on face; in thin, dark complexioned 
subjects; after abuse of mercury ; yellow liver spots in middle or later life, 
with chronic constipation. 

Erythema caloricum (chilblains). — Eedness of toes and fingers, with sen- 
sation of heat and sticking as if they had been frozen; worse from touch and 
pressure, better from washing with cold water. 

Eczema about the mouth or nose (occasionally on the bearded parts of the 
face), the hands, arms, labia, penis or perineum may call for nitric acid, espe- 
cially if the general symptoms of this drug are present, and the splinter-like 
sensations aggravated by touch are felt in or adjacent to the lesions. The 
form of predominating eruption is not important : papular, vesicular, pustular, 
crusted, fissured or scaly types yield equally to this indicated remedy. A strong 
urinous order of the urine or an acid or urinous odor of the perspiration may 
suggest this drug. 



598 NUX MOSCHATA 

Carbuncle. — Splinter-like and burning sensations in or about the affected 
area, worse from touch: in the scrofulous or those who have used mercury 
■freely; emaciation, weakness, mental irritability and depression. Especially 
when situated near the mucous outlets or when recurrent. 

Syphilis. — Primary sore, clean in appearance, with sharp stitching sen- 
sations in or near lesions ; secondary syplvilides of any form which do not yield 
to mercury; lesions with broad areola and accompanied with unusual sensations 
in all parts of the body, emaciation and weakness; whitish ulcerating lesions of 
the mucous membrane, with offensive odor of secretions and painful fissures at 
muco-cutaneous otitlets; ill conditioned ulcers of the skin, with irregular 
edges which bleed easily ; vegetating lesions especially on genitals, anus or face ; 
band-like constriction and headache as if in the bones. Sensitiveness and 
splinter-like pains over malar or other bones, with threatened caries; many 
symptoms worse from exposure of skin to air or wet, at night, better from 
gentle rubbing and warmth. 

Leprosy. — Nitric acid should be studied in cases of macular or tubercular 
leprosy when some of its characteristics are observed. 

Yaws. — Various sized dermoid growths with dark areola becoming fungoid 
in character and later tending to ulcerate, accompanied with swollen glands, 
pains in extremities, fever and perspirations ; especially in cases involving the 
mucous membrane or most marked at muco-cutaneous outlets. 

Keloid. — Nitric acid may be thought of in keloid when the growth is con- 
fined to the mid-sternal region. 

Naevus pigmentosus. — Acquired forms, especially warty type; on face, 
neck or hands and tending to multiply persistently. Bleeding warts. 

Nitric acid should be given in aqueous solution and seldom above the sixth 
decimal attenuation. 

NUX MOSCHATA 

Nutmeg exerts an inhibitory influence on the heart and on the normal se- 
cretions and excretions and causes various nervo-mental disturbances. The 
skin is rendered cold, dry and pale, and if tinged with red soon fades again. 

Anidrosis. — Absence of perspiration with coolness of the surface, dry 
mouth, throat or other mucous surfaces, and sensitiveness to cool moist air; in 
hysterical subjects of changeable disposition who are subject to absent-minded- 
ness, bloating of the abdomen, aphonia suppression of the menses, etc. In 
pregnant women. 

Acne indurata. — Pustules on the face, with wide areola, tension and burn- 
ing; other parts cold and dry; in hysterical subjects with characteristic 
symptoms. 

Nux moschata should be given in low attenuation, first or second decimal. 



NUX VOMICA OLEANDER 



NUX VOMICA 

This drug irritates the spinal cord and it- counter pan- 111 the brain, and 
thereby causes a large variety of reflex motor and sensory disorders. The nutri- 
tive functions are especially disturbed or perverted, and consecutive malnu- 
trition and vasomotor reflexes of various sorts may be added to the ea 
symptoms. In the cutaneous sphere Bweat disorders, circumscribed h 
mia. follicular papules and large pustules are the chief objective feal 
These arc usually located on the face, neck, chest, inner forearms, sides of the 
lingers, thighs and knees. Sensations are qoI constanl ; burning, itching, ten- 
sion, soreness and gnawing arc the mosl common. When preseni they are 
usually worse from the first effecl of warmth of bed or room, in the forenoon, 
after eating, and on the extremities; arc better in the afternoon, and tempo- 
rarily from scratching. 

Acne simplex or indurata. — Papules, tubercles and pustules on face, tin- 
larger surrounded by redness, painful in forehead, worse forehead, temples and 
chin; in brunettes of sedentary habits, thin, irritable, subject to dyspepsia, 
headache, constipation, insomnia, etc., characteristic of uux vomica. 

Chromidrosis of the trunk associated with gastric disorders. 

Lichen planus, when the eruption is located on the inner surface of the 
forearms, thighs, or sides of the body, and attended with neurotic symptoms 
resembling the characteristics of mix vomica, may be cured with this drug. 

Rosacea. — Associated with indigestion, with craving for stimulants, con- 
stipation; in persons of sedentary habits with symptoms n-urs,' in the morning 
after eating, better in afternoon and evening. Sensations of tension and sore- 
ness in affected parts relieved by scratching. 

Nux vomica may be used in a variety of attenuations. While the sixth 
decimal is often effective, not infrequently a lower attenuation is required. 



OLEANDER 

Oleander produces narcotic irritant and paralyzing effects through the 
cerebro-spinal system, which are manifested by a bursting or throbbing frontal 
headache, mental weakness or confusion, tendency to convulsions, gastric dis- 
turbances, and cutaneous paresthesia with extreme sensitiveness, and an especial 
elective affinity for the skin of the scalp and contiguous non-hairy parts. St »- 
sations may exist alone, precede or attend the formation of scales an outbreak 
of papules, vesicles, or pustules on the scalp or face, or pruritic sensations may 
be felt here and there without eruptions. The most characteristic sensation i> 
a biting itching, though gnawing, sticking, burning, smarting and soreness are 
attributed to this drug. Aggravations occur from undressing, friction o( the 



600 OPIUM (MORPHIA) 

clothes and from rest. Temporary relief follows from scratching or the sensa- 
tion may be changed to smarting or rawness thereby. 

Eczema of the scalp (occipivt), behind the ears, on the cheeks, or forehead 
with pruritic sensation and sensitiveness out of proportion to the extent of 
serous exudation, scaliness. or the number of papules or pustules, especially if 
biting, itching sensations are felt in non-eruptive regions and are aggravated 
by frictions of the clothing, may be cured with oleander. 

Pruritus. — Particularly of the scalp with biting, itching or crawling sen- 
sations, worse at night; of legs or other covered parts, worse from friction of 
the clothes, especially while undressing. Associated with indigestion, pulsa- 
tions in the stomach, a throbbing, occipito-frontal headache and sensitiveness 
of the scalp. 

The sixth decimal attenuation is generally employed. 



OPIUM (MORPHIA) 

Opium acts on the whole nervous system causing depression of the conscious 
and automatic functions and excitation of subconscious or inco-ordinate action, 
manifested by various sensory and motor disturbances. In the cutaneous 
sphere pruritic sensations, congestion, circumscribed inflammation or disturb- 
ances of nutrition may appear varying in nature and degree according to the 
susceptibilit)^ of the subject. 

Pruritus. — In old people with coldness of the parts, mental dullness, 
twitching of the flexor muscles, constipation, itching, biting, crawling, etc. ; 
sensations (especially of the head, face, genitals or extremities), excited or 
worse from fright, anger and at night. 

Urticaria. — In children or old people following fright, anger or use of 
stimulants. At night when half awake, must uncover (though skin is cool 
to touch) the bed feels so hot. During dentition attended with drowsiness, 
twitching of flexors, constipation and cool perspirations. 

Scleroderma. — Sweating, coldness, swelling, purplish, bluish or violet red- 
ness of affected parts in early stages ; pale, shriveled, tawny, leathery and con- 
tracted appearance in later. stages, with mental dullness, drowsiness, muscular 
spasms and unsteadiness, and unrefreshing sleep. Most symptoms ivorse at 
night from heat, stimulants and while perspiring. 

Atrophia maculosa et striata. — After fevers or other systemic disease. 
Bluish, purplish or brownish spots chiefly on face, neck or limbs. Associated 
with sensitiveness to warmth yet lack of heat in the skin, mental and physical 
dullness, constipation, etc. 

The remedial effects of opium on the skin may be usually obtained from the 
sixth decimal; occasionally a lower attenuation is required. 



OSMIUM— PARIS QUADRIPOLLA PETROLK1 \l 901 



OSMIUM 

This metal produces an irritant effecl on the mucoufl membranes, diftorbt 
the nutrition and functions of the eyes and skin in a limited hut characteristic 
way. It increases and gives odor to local perspiration, causes adhesions of the 

nail fold, and gives rise to macular, nodular, papular, vesicular and crusted 
lesions. These are usually located on the back of hands, face, arm-, neck, 
trunk and legs, with a tendency of eruptions to appear on the lower half of the 
body as they subside on the upper parts. Sensations of crawling, itching, sore- 
ness and burning may be felt, and become worse on exposure of the surface 
while dressing and undressing morning and night. 

Bromidrosis. — Sweat in axilla smelling of garlic, worse evening and night. 
With concomitant catarrhal affections. 

Pterygium. — Fold remains attached to growing nail, worse right middle 
finger. 

This remedy may be used in the sixth decimal. 

PARIS QUADRIFOLIA 

This plant acts evidently on the peripheral centres of innervation causing 
pronounced neuralgic pains, pruritic sensations and a sparse eruption of vesicles. 
General indications for this drug are great sensitiveness to offensive odors, im- 
aginary foul smells; parts involved feel very large or heavy. The favorite 
locations of sensory disturbances are the left side of face. neck, arm and thorax. 
Sensations are worse nearest the spine, evening and morning, on waking. 

Herpes zoster. — Of the left side — facial, cervical, brachial or intercostal — 
with severe neuralgic, biting, sticking, burning pains worse nearest central 
origin of nerves morning, evening, from touch and friction. Eruptions slow 
to appear, and pains continue after eruption has appeared; great weight on 
back of neck and general sense of increase in size. 

Paris quad, acts well in the first decimal attenuation. 

PETROLEUM 

AYhile the action of petroleum is not well understood, it is known to derange 
the functions and disturb the nutrition of the tissues of the mucous membrane 
and the skin, and to set up a train of systemic disturbances often characterized 
by headache, irritability, vertigo, weakness, nausea, dyspepsia, etc., which 
usually become worse from passive motion. 

It acts on the sweat and oil glands of the skin, causing disturbance in their 
functions and sometimes consecutive inflammation and atrophic changes. The 



602 PETROLEUM 

favorite locations for disturbances are the occiput, behind the ears, on the 
hands, fingers, feet and toes. Sensations of burning, sticking, itching, cutting, 
soreness or tickling often attend the onset and course of the disorder. These 
are likely to be worse morning and evening, from pressure of clothes, scratch- 
ing and in cold weather. 

Hyperidrosis or bromidrosis. — Sweat on feet in cold weather, with burning, 
sticking or soreness, worse in cold weather. Has cured fetid perspiration of 
feet when indicated by local or general symptoms. 

Seborrhoeic dermatitis. — Eruption between toes, suitable to cases which 
have originated from sweating of the feet. Ends of toes are apt to be rough 
at outer line of contact with adjacent toes. 

Comedo. — Orifice of follicle enlarged and containing dry and friable epithe- 
lium, which cannot be squeezed out; nodular infiltration about follicles which 
contain hair. Adapted to cases which originated from local applications to 
the skin ; in the dark complexioned with coarse hair. 

Acne. — Pustules with white tips on nose and other regions of face, follicu- 
lar swellings and man} r comedones difficult to express. Unhealthy- appearance 
of the skin of the affected region, easily suppurating. 

Alopecia. — Palling of hair in persons subject to occipital headache, occa- 
sional vertigo or dyspepsia characteristic of petroleum. 

. Conglomerate suppurative perifolliculitis. — Patches of honeycombed 
groups of follicles, elevated, thick and inelastic; in some cases follicular abs 

Subacute and chronic eczema, moist, crusted, dry, or fissured, not infre- 
quently show indications for petroleum. "When seated at the occiput, back of 
the ears on the scrotum or vulva, opposing surfaces of the thighs, or between 
the fingers and toes, an irritating serous exudation gives the parts a raw or 
excoriated appearance, and the discharge may lie profuse after scratching, ac- 
companied with excessive burning or smarting. Occasionally the discharge has 
a fetid odor from admixture of sweat. Eczema intertrigo in infants or stout 
adults may call for this drug. On the hands or arms the eruption is apt to 
alternate from moist oozing of the surface to rather thick crusting, Avhile on 
or near the tip of the fingers the skin is most often rough, thickened or fissured. 

Psoriasis of the hands has been cured with petroleum. It is indicated here, 
on the scalp, arms, and possibly elsewhere when the skin is unusually sensitive, 
the lesions are easily irritated, inflamed or fissured, and then burn or sting. 
Aversion to the open air and aggravations in cold weather are important indi- 
cations, while stiffness or cracking in neighboring joints are suggestive con- 
comitants. 

Syphilis. — Secondary syphilides. moist papules on the genito-anal region 
especially on the scrotum, also between toes, easily irritated by friction which 
excites moderate disturbances of sensation: scaly, fissured lesions on hands, 
particularly at finger tips; loss of hair, headache, vertigo, weakness, etc. 
General aggravations night and morning, from riding and in cool weather. 
Leprosy. — Premonitory headache, weakness, bone pains, dyspepsia general 



PHOSPHOR! 8 608 

or local bypera sthesia and sensitiveness to cold ; yellow ish, brow ni ddish 

macular or tubercular lesions with or withoul vt i bullae, on face, trunk, 

legs or hands; stiffness in fingers, fissures and atrophic changes in tips; toes 
drawn sideways with sensations of constriction, pressure and drawing 
frozen; numbness of extremities, skin easily irritated; ulcers with deep ■ 
aversion to the open air. 

Naevus pigmentosus. — Hypertrophic (elevated) moles may be sometimes 
cured with petroleum, locally or Internally. 

Lymphangioma. — .Small celled growths In Bpots along lymphatics and 
veins; similar situated somewhat solid ami sensitive lesions (L. tuberosum 
multiplex). Dread of open air and general hyperaesthesia of the surfa* 
slight pressure. 

Lupus erythematosus. — Active cases attended with Bigns of inflammation, 
especially on occiput, behind cars, on scalp or lace: skin easily irritated h\ 
local applications or friction, sometimes cracks, and then is attended with 
burning, stinging, or itching sensations, ii-m-st: from pressure, scratching and 
in cold weather. 

Verruga. — On fingers or tips of, with pulsating, suppurating or sore sensa- 
tions if irritated or exposed to cold. May be applied locally also in crude 
form. 

Good effects from petroleum can usually be obtained from the third to 
.sixth decimal attenuation. 

PHOSPHORUS 

This energetic element, introduced into the body, firsl stimulates the ; 
pheral capillaries, then disorganizes the tissues and the blood, and finally if 
long continued, may cause fatty or otber degenerative changes in any ti 
The changes in the capillaries and in (lie blood predispose to hemorrhages 
from apparently slight causes and in the tissues to deep-seated inflammati m or 
degeneration. On the skin it may give rise to nearly all forms of priman and 
secondary lesions according to the dose and susceptibility of the individual. 
Clinically it is comparatively useful in its uncombined state only in hemor- 
rhagic affections or for eruptions which bleed easily, whatever their form, and 
for conditions apparently dependent on local or general defects of innervation 
and nutrition. Location is unimportant. Sensory disturbances vary widely 
from the anaesthetic to the moderate or extreme hyperaesthetic or parsesthetic. 
Among general symptoms are mental and physical prostration, heaviness of 
the whole body, sleepiness. Aggravations are apt to occur before midnight, 
during a thunder storm, and from lying on the left side or back. 

Phosphorescent sweat, Bromidrosis. — Sweat luminous mi forehead: 
phosphoric odor, garlicky odor, sulphurous odor. 

Seborrhoea sicca.— Much dandruff, biting sensations, little itching: when 
general symptoms indicate phosphorus. 



604 PHOSPHORUS 

Alopecia areata. — Hair falls out, bald spots above ear, roots of hair dry, 
with or without dandruff, especially when there is soreness or bruised pain in 
head, made worse by pressure. 

Lentigo, Chloasma. — Phosphorus is indicated for freckles or liver spots of 
the face, neck, hands or elsewhere when the pigmentations are made more 
apparent by marked paleness of the unaffected portions of the skin, worse from 
getting heated, sweating, constipation, at the menstrual period, in erotic 
females, in those subject to bleeding piles or other characteristic hemorrhages, 
and especially when the general symptoms of emaciation, weakness, etc., are 
characteristic of this drug. 

Urticaria pigmentosa. — Elevated crimson wheals, darker in centre or be- 
coming brownish and persistent; in tall, slender subjects who take cold easily; 
general symptoms worse during a thunder storm. 

Pellagra, Acrodynia. — Emaciation, loss of power in the legs, vertigo; 
macular, papular, vesicular or pigmentary lesions attended with burning sen- 
sations, worse before midnight. 

Purpura. — Petechial spots, generally distributed, or larger bluish spots on 
the legs. In tall, slender subjects with gastro-intestinal or hepatic disturb- 
ances. 

Dermatitis herpetiformis. — Grouped vesicles without much areola; phys- 
ical prostration, heaviness, sleepiness. 

Pemphigus. — Vesicles or blebs without areola generally distributed at- 
tended with moderate sensations of heat, burning, soreness or tension. In 
subjects suffering from debility, overwork, shock or other nerve exhaustion. 
Early stage of P. vegetans or P. foliaceus when general symptoms correspond 
to phosphorus. 

Favus, Tinea tonsurans. — Later stage for threatened baldness in round or 
oval spots; soreness or bruised sensations in scalp worse from pressure; phys- 
ical and mental depression or apathy. 

Ecthymatous ulcers, Syphilis. — Specific or non-specific ulcers which 
.have developed from small sores, bleed easily or show raw bleeding base on re- 
moval of crusts, especially wben located on buttocks or thighs; crusts blacker 
at centre surrounded by deep red areola and unusually sore or sensitive to touch. 

Sometimes useful in secondary sijpliilides in tall, slender, weak, or scrofu- 
lous subjects, with painful heaviness of whole body and general or special 
aggravations before midnight; scaly lesions of palms and soles, extensor sur- 
faces or about joints, with red or bleeding points, on forcible removal of scales. 
Syphilitic periostitis, caries or exostosis, especially of long bones, with great 
heaviness in all the parts and sensitiveness of affected area. Pains worse at 
night and from hot applications. 

Leprosy. — Yellowish, reddish or brownish macular spots, patches paler in 
the centre and anaesthetic or paraesthetic, deeper color and hyper-aesthetic at 
periphery; intercurrent hemorrhagic bullae; tubercular lesions which soften 
and discharge a yellowish-brown, bloody or sticky fluid; tall, slender, emaci- 
ated, weak victims ; with generalized sensations of pricking and numbness. 
worse at night and when lying on back or left side. 



PH0SP110RKJUM ACIDUM 

Tuberculosis verrucosa, Verruca. — Tuberculous or ordinary wan-, sub- 
ject at times to painful, sore or itching sensations, show a tendency to bleed, 
suppurate or cause inflammation of adjacent skin; thin, poorly nourished, 

scrofulous subjects with pale yellowish complexion. 

Lymphangioma. — Associated with tuberculous airections or arising pri- 
marily from derangements of the capillary circulation; warty-like growths 
containing vesicles with thin transparent or milky fluid, sometimes purplish 
from extravasations of blood, or dilated capillaries show here and there; 
dilated vessels (lymphangiectasis), or lesions rupture and discharge clear or 
milky fluid; associated with general conditions calling for phosphorus. 

Mycosis fungoides, Verruga. — Variously shaped growths, some of which 
become warty or fungoid in character, bleed easily, ulcerate and are attended 
in early stage with some degree of burning, itching or other painful sensations, 
generally worse before midnight, etc. Especially when constitutional symptoms 
indicate phosphorus, this drug ought to prove helpful in these rare affections. 

Phosphorus should be given in the sixth decimal for most cutaneous affec- 
tions, sometimes lower and rarely higher. 



PHOSPHORICUM ACIDUM 

This acid produces an apathetic type of weakness, such as might arise from 
lack of sufficient nutritive matter to meet the demands of the growing body or 
the loss from undue waste. Metabolism is defective, and the sexual, digestive, 
osseous and cutaneous systems especially suffer thereby. With a disinclination 
for all exertion there is a certain contradictory disposition to move about. The 
swollen glands may be painless, but bone pains are pronounced and of a burn- 
ing, tearing, gnawing character. On the skin, macular, papular, tubercular, 
vesicular, pustular or ulcerative lesions may appear, with general formication, 
but rarely with painful or persistent sensations in or near the eruption. The 
more common locations are the face, neck, arms, hands and legs. Symptoms 
are usually worse at night, at rest, from cold and touch, and are better from 
motion and warmth. 

Acne simplex and indurata. — Pale face, papules, tubercles and pustules 
on face and shoulders, worse on forehead, nose and about mouth, sensitive only 
to pressure; particularly in overgrown boys or girls with early sexual propen- 
sities; or in older persons suffering from over-sexual indulgence or abuse. 

Alopecia and canities. — Falling of hair; "hair becomes gray early and 
falls out, the effects of mental strain;" headache worse in vertex, soreness of 
scalp only on touch; in early middle life with symptoms corresponding to 
phosphoric acid. 

Onychia. — Stitches in thumb extending under nail: nail grows into flesh 
of toes; sticking and jerking sensations on touch: numbness or falling asleep 
of fingers and toes in cases with characteristic debility. 



606 PHYTOLACCA 

Rosacea. — Associated with chronic intestinal disorders, anaemia, chlorosis, 
sexual excitement or abuse^. mental and physical apathy; formication and 
sometimes deep burning sensations. Symptoms worse from rest; better from 
warmth and motion. 

Pompholyx. — Debilitated subjects, vesicles on balls of toes, soles and 
fingers, with deep burning, tension and soreness, worse from cold and touch, 
better from warmth. 

Furuncle. — Boils on face, neck, thigh or in axilla? ; stinging, burning pains, 
sensitive to touch and soreness of unaffected skin; weak, apathetic subjects, 
particularly overgrown boys or girls with early sexual propensities, or older 
persons suffering from over sexual indulgence or abuse. 

Verruca. — Large, fleshy, jagged, moist or bleeding warts about mucous 
orifices, at times subject to burning or stinging sensations, worse from cold. 
better from warmth; in young people who have grown up rapidly, seem de- 
bilitated thereby and show a distaste for mental activity. 

The lower attenuations, second to fourth decimal, give the best and quick- 
est results. 

PHYTOLACCA 

This drug excites inflammation of the glands (particularly of throat, breast 
and kidneys), fibrous, mucous and cutaneous tissues, producing effects some- 
what like those of scrofula, syphilis, malignant affections; from mercury and 
kali iodide, with general symptoms of prostration and lithsemia: local sensa- 
tions of painful soreness, burning, shooting or tension of affected parts which 
may extend or radiate to near or distant regions. Symptoms are worse at night 
and from damp weather, better often from lying down and on going out of 
doors. Under its influence the skin may become dry, shrunken, pale or lead- 
colored and macular, squamous, papular, or pustular lesions appear. A particu- 
lar feature of phytolacca is that more generalized eruptions appear first upon 
the head and extend downwards. Clinically it is most useful in the early 
stages of cutaneous disease to abort or modify their natural course. 

Psoriasis when it begins first on the scalp and spreads downward over the 
body, especially if there is a history of scrofula, remote syphilis or excessive 
use of the iodide of potash. 

Tinea tonsurans, T. barbae. — Scaly spots first on scalp and extending 
later to face or neck, with sensations of general or local soreness. 

Furuncle, Carbuncle. — In the lithaemic or debilitated; slow to develop, 
with burning tense pains,, worse at night; associated with swelling of lymph 
glands and general paleness of the skin. 

Lupus vulgaris, Scrofuloderma. — Primary lesions beginning on face or 
neck and slowly extending in a downward direction; with swollen glands and 
leaden hue of the skin : aching or soreness in the muscles or bones at night or 
in damp weather. 



PICRIC! M AUDI \l 807 

Syphilis. — Secondary or tertiary syphilide in pale, lithaemic or debilitated 
subjects; beginning on the head or upper trunk and spreading downwards; 
associated with mucous patches or ulcers of the mucous membrane and bwi 

glands; periostitis or nodes especially of long bones with nocturnal pains ; with 

rheumatic condition of joints, muscles or fascia attended with shifting pains; 

aggravations at night, from damp weather, and general relief from lying down. 

Paget's disease. — With pains radiating from the nipple; lameness or 

painful sensation of fluid flowing into the breast; swelling or soreness of 
glands and pale cachectic hue of the skin : sometimes in ulcerating Btage when 
base of ulcer looks fatty and edges are sharp cut: aggravations first part of 
night, from damp weather, temporary reUef from bathing parts with cold 
water or cooling solution and in recumbent position. 

Carcinoma. — Iiurperable cases of primary or recurrent cancer attended 
with pains radiating from affected region, swollen glands, early cachexia and 
prostration; punched out looking ulcer with lardaceous base; pains or condi- 
tions ivorse first half of night, in damp weather and from warmth of part; 
some relief or comfort from cold bathing of affected region. 

Phytolacca probably always exerts its best etl'ect in low attenuation.-. 
to third decimal. 

PICRICUM ACIDUM 

In moderate toxic doses picric acid alters the blood, deranges innervation 
by its action on the nerve centres, and lessens elimination by inflaming the 
kidneys. General secondary effects (even from small doses) are weariness. 
fatigue from slight mental or physical effort, impaired will power and indiffer- 
ence. In the skin it may cause changes in color of face to a yellowish hue and 
the appearance of papulo-pustular.vesieulo-pustular or pustular lesions, accom- 
panied with stinging, burning, itching, tense or painful sensations, worse from 
pressure, motion, and at night; better from rest and cold applications. 

Impetigo contagiosa. — On the lace with sero-purnlent exudation which 
dries into rather transparent crusts; especially in debilitated children who tire 
easily, feel better while at rest and local pains from cool applicai i< 

Furuncle, Carbuncle. — Boils on face, neck or in the ears; carbuncles on 
back of neck or face; in neurasthenic or hysterical subjects who are exhausted 
by moderate effort; associated with periodic menstrual or sexual neurasthenia ; 
with occipital headache, icorse from trying to think, relieved by cool applica- 
tions or cool air; sensations worse from motion, pressure and at night, some- 
times better from rest. 

Picric acid can be employed in the sixth decimal for most case-. 



608 POPULUS CANDICANS— PSORINUM 



POPULUS CANDICANS 

This drug acting on the peripheral nerves of sensation produces well- 
marked anaesthetic and paresthetic disturbances. 

Anaesthesia. — Worse over back, abdomen,, finger ends, mornings and be- 
fore menses ; associated with rheumatic pains ; talkative ; apprehensive about 
recovery. 

Pruritus. — Surface harsh, dry and cool with heat, burning or stinging 
below the surface as if an eruption was about to appear; better from hot appli- 
cations ; loquacity ; periodic attacks. 

Perforating ulcer of foot. — In the early stages when coldness and anaes- 
thesia of the part are pronounced. 

^_Populus cand. may be administered in the second or third decimal attenua- 
tion. 

PSORINUM 

This product of disease when introduced in the human body deranges the 
secretions and devitalizes the tissues of the skin to a degree which lessens its 
resistance to morbid processes, irritates the lymphatics, depresses the functions 
of other organs, and induces general debility and mental depression and fret- 
fulness. 

The skin lesions are unhealthy in type, and both the physiological and 
pathological secretions are usually foul. Vesicles, pustules and crusts pre- 
dominate, though sometimes situated on a scaly area or about the border of a 
scaly patch. The location of eruptions may be general or limited to the face, 
hands, arms, legs, chest or back. Sensations of itching or crawling are pro- 
nounced, sometimes so intolerable that the lesions are scratched until they 
bleed. The sensations are worse from warmth of bed or exercise, often in the 
open air, and are sometimes better in the morning, while at rest and indoors. 

Chronic eczema of various types which do not yield to indicated treatment 
may respond to this remedy. It is especially adapted to a persistent and 
offensive form of eruption apparently due to an ill-defined diathesis (psora). 
Such patients generally show a dirty or yellowish hue of the skin, complain 
of sudden and offensive perspirations and constantly worry about themselves. 
They are always worse from the warmth of bed as in genuine scabies. Occa- 
sionally such chronic eczemas are characterized by a recurrence with the return 
of cold weather until they are permanently cured. In prolonged cases the 
lymphatic glands may remain persistently swollen. 

Scabies. — Debilitated, fretful subjects : neglected cases with offensive odor 
of secretions and dirty complexion ; scrofulous types with pustular lesions here 
and there which persist under treatment : itching which induces tearing of 



PULSATILLA (;,, '• , 

the skin with the finger nails; aggravations from warmth of bed before mid- 
night. 

Pediculosis. — Associated with yellowish or unhealthy appearance of the 
skin, disagreeable odor of the physiological secretion*, Bwollen glands or other 
signs of scrofula, etc. Sensations marked and worse from warmth <>f bed- 
Helps to restore normal resistance of the skin. 

Ecthyma, Tuberculosis orificialis, Scrofuloderma.— Offensive odor of all 
secretions even after cleansing parts; -allow, sickly, delicate, irritable subjects; 
ulcers' with thin ichorous discharge oozing for hour.- continuously ; symptoms 
generally worse in first half of night, from warmth, out of door- better in 
morning and from rest. 

Verruca. — Groups of smooth warts on fingers of left hand, chin or abonl 
mouth, sometimes moist and itching, worse from warmth, may be helped to 
disappear with psorinum internally and locally, especially if the constitutional 
conditions indicate the remedy. 

Psorinum should always he administered in the higher attenuations, sixth 
to thirtieth decimal. 

PULSATILLA 

The polycrest is rarely indicated in affections of the skin not dependent in 
some measure on disturbances of the mucous or serous membranes, generative 
organs, etc. It should be studied in its relation to disposition and in all its 
various characteristics when certain cutaneous symptom-; suggesi it as a 
remedy. 

The form of lesions and their location is not important. Erythema, pap- 
ules, vesicles and pustules are most common, and tic face shoulders, chest, 
back, neck and groins the more frecprcnt site-. - >• of burning, itching, 

biting, pulsating, prickling and sticking may he felt. The really important 
indications are the marked aggravations from warmth of bed. while in a warm 
room, from lying on the side, from eating rich, fatty food or fruit; and the 
equally marked relief from the cool open air. a cool room, and from Lying on 
the back. 

Hyperidrosis. — One-sided sweating at night; on feet every morning in bed. 

Acne. — Papules and pustules on forehead face, chest, shoulders and back, 
with occasional throbbing, pricking, etc., worse in a warm room : in Lachrymose 
young women fond of rich food, with characteristic dyspepsia, delayed men- 
struation or other Pulsatilla conditions. 

Eczema in children and young adults sometimes presents underlying con- 
ditions similar to the effects of pulsatilla: rarely the typical modalities named 
above have been observed and prompt cure- effected with this drug. Su< 1: 
are acute or subacute but never chronic. Occasionally they have a tendency 
as one area improves to appear suddenly in another region corresponding to 
the shifting tendency of pulsatilla. 



<>10 RANUNCULUS BULBOSUS 

No single attenuation of pulsatilla can be named as the best. The writer 
selects the third decimal for new cases. 



RANUNCULUS BULBOSUS 

This drug acts selectively on the peripheral nerves and gives rise to abnor- 
mal sensations which have been described as neuralgic, rheumatic or myalgic 
in character. These may be accompanied with herpetic eruptions or a super- 
ficial spreading inflammation of the skin. Besides the neuralgic varieties of 
pain, burning, itching, stinging, crawling or pricking sensations may be felt 
in or about the affected area. Locations of cutaneous symptoms are along the 
lines of superficial nerves of the hands, arms, face and trunk. Aggravations 
occur from changes of temperature and weather, from scratching, and in the 
evening. 

Neurotic eczema with vesicular and crusted lesions, unilateral in distribu- 
tion (especially of right side), attended with unusually severe pains or burn- 
ing, itching, intolerant of scratching and worse from changes of atmospheric 
temperature, may be benefited by the action of ranunculus. 

Dermatitis repens characterized usually by a one-sided spreading type of 
inflammation with abrupt borders and serous discharge, indicating a probable 
involvement of the cutaneous nerves, may in some cases be met by similar 
symptoms and conditions in the pathogenesis of ranunculus, the ulcerations 
from which are described as "spreading with eroded sharp borders." 

Herpes zoster. — Especially affecting the ophthalmic branch of the fifth 
nerve with intense ciliar}^ pains, iritis, etc. Violent neuralgia of intercostal 
or other nerves with eruption of transparent bluish, elevated vesicles tending 
to assume oval groups, or intense burning, stinging or pricking sensation dur- 
ing attack and occasional neuralgic pains, worse from changes of temperature 
or weather, and in the evening. 

Dermatitis herpetiformis. — Bluish vesicles crowded together in oval 
groups, contents changing to dark yellow, some rupture and form spreading 
superficial ulcers. Eruption preceded or attended with intense burning, itch- 
ing, stinging, pricking or sharp pains, preventing rest night or day; most 
symptoms worse from changes of weather and in the evening. 

Pompholyx. — With unusually severe pains and tendency of eruption to 
spread; sensations worse in the evening. 

Eanunculus produces its best effects on the skin in the third to sixth deci- 
mal attenuation, depending on the susceptibility to its influence. 



RHODODENDRON RHUS TOXICODENDRON «'M 



RHODODENDRON 

Like Pulsatilla, this drug is rarely indicated in the skin disorders not con- 
nected with other conditions, particularly arthritic and rheumatic affections. 
worse before a storm, in cold, damp weather, while at rest, mornings. In a 
limited way it deranges perspiration and causes a sparse outbreak of macular, 
papular and pustular lesions with sensations of burning, pricking and tension. 

Hyperidrosis and bromidrosis. — Sweat on hands, worse at tips of lingers, 
at night; fetid in axilla, smelling of spice, worse mornings. 

Acne. — Pustules on forehead, shoulders and back; in rheumatic or neu- 
ralgic subjects with typical modalities. 

Rhododendron should always he given in a low attenuation, first to third 
decimal. 

RHUS TOXICODENDRON 

The susceptibility to poison oak or to poison ivy varies widely in different 
persons. It shows an affinity for the muscular, fibrous, sero-fibrous and gland- 
ular (epithelial) tissues, and through these it acts on the mucous membranes 
and most prominently on the skin. From the mildest irritant effect (ery- 
thema) may follow moderate or severe types of inflammation, characterized by 
serous exudations, cedema or infiltration of the cellular tissues. Profound sec- 
ondary effects on the organs of animal life and which resemble the states 
observed in low fevers may result from large or continued doses. 

The general characteristics of rhus are restlessness (with or without 
anxiety), debility — sometimes paralytic in feeling, aggravations of all symp- 
toms from rest, exposure to cold and wet. on beginning to move, and temporary 
relief from longer motion. 

On the skin nearly every form of inflammatory lesion may he produced by 
rhus. These eruptions, as a rule, tend to spread rather than to penetrate deeply 
into the tissues. Macules papules, vesicles, pustules, the consequent scales and 
crusts are the most common lesions and of these vesicles the most typical. The 
localization of eruptions may be general or show a preference for the face, ex- 
tremities or genitals. Sensations of itching and burning are usually most 
pronounced, but tingling, smarting, stinging and tension are not uncommon. 
These are generally worse from local warmth, cold and wet weather, at night, 
after rest, from light scratching, and are sometimes relieved by local told, dry 
weather, by moving, and by hard pressure or scratching. 

Erythema multiforme, E. nodosum. — Erythematous spots on the face or 

extremities, tending to spread at the peripbery and intensely congested or to 
vesiculate at the centre, with restlessness, burning, tingling, stinging, itching, 
tense or rheumatoid sensations, worse from rest, warm applications, wet and 
cold weather, light touch or scratching, and often relieved by cold applications, 



(512 RHUS TOXICODENDRON 

motion and hard pressure. Early stages of E. nodosum, with hard bluish-red 
swellings, chills and fever, soreness and aching pains in extremities and char- 
acteristic modalities. 

Erythema calorica (chilblains). — In rheumatic subjects, from exposure 
to cold and wet, with intolerable stinging, sticking, burning, itching, belter 
from cold applications, rubbing, motion, and worse from rest and warmth. 

Eczema calling for rhus is usually acute or subacute, rarely chronic, and 
is seldom uniform in type. Erythema papules, vesicles, pustules, etc., min- 
gling perhaps without order, but the signs of vesiculation are rarely, absent, 
and the changes in the appearance of the surface unusually frequent and rapid. 
At one time the surface may be red, moist or raw, at another covered by thick 
yellowish or brownish crusts, or papular and dry, or again assume quickly a 
dark red swollen appearance resembling erysipelas. A tendency of the vesicles 
to become quickly purulent is a special indication for rhus. Itching is usually 
pronounced, especially when the hairy parts are involved. The secretions are 
nearly always acrid, irritating to the unaffected skin and often offensive to 
smell as crusts form. In persistent cases the lymphatic glands may become 
swollen and hard, and in chronic cases the affected skin changed to a leathery 
consistence and thickness, and subject to intercurrent attacks of active inflam- 
mation. In such cases the flexor surfaces of the joints of the extremities are 
commonly the sites of the disease. 

Urticaria. — With considerable swelling of the skin, rheumatic pains. Le- 
sions of variable size and shape, first appearing after midnight or after expo- 
sure to cold and wet. Burning itching, relieved by cold applications and by 
walking about. Chronic urticaria with characteristic modalities. 

Purpura, P. hemorrhagica. — Brown spots most numerous on inner ankles, 
with swelling of skin. Bheumatoid pains and constant restlessness at begin- 
ning of attack. From exposure to wet and cold. P. hemorrhagica with tongue 
dry in centre, weak, variable pulse and great restlessness. 

Peliosis rheumatica.— Following exposure to cold or wet, severe pro- 
dromal rheumatic pains in legs or arms, fever, dry tongue, symptoms worse 
from rest, better from repeated motion. 

Rosacea. — In rheumatic subjects, tip of nose swollen, intensely red. painful 
to touch; soreness of inner nose, nosebleed when stooping. Burning, tense 
sensations relieved by cold applications. Aggravations from cold, wet weather. 

Herpes zoster. — Caused by getting wet while heated. Pre-eruptive myal- 
gic pains of one region, worse after rest or attended with great restlessness pre- 
venting sleep. Swelling with first redness of the skin, burning, stinging pains. 
worse from scratching. Vesicles tending to confluence are accompanied with 
unusual itching and persistent restlessness. 

Dermatitis herpetiformis. — When caused or aggravated by wet and cold; 
in rheumatic subjects or when preceded by characteristic rheumatoid pains, 
itching of the skin, etc.; multiform eruption attended with intense itching, 
burning or pricking sensations and great restlessness. Symptoms and condi- 
tions worse from rest and better from motion. 



RUMEX CRISPU8 618 

Pemphigus. — Acute cases or early stage of chronic pemphigus vulgaris, 
especially when apparently caused by exposure to cold and dampnee 
attended with (-ever, physical restlessness, prostratinn, aching pains and souk; 
pruritic sensations. 

Scleroderma. — Symmetrical form, skin hard like leather; tension, aching, 
heaviness and stillness in parts, worse after rest, before and during storms, 
from getting wet and from over-exercise. Especially adapted to cases follow- 
ing rheumatism, excited by exposures to cold and damp with general sensitive- 
ness to cold. 

Insect bites. — Inflammation from bites, with spreading infiltration and 
swelling of the skin, intense pruritic sensations, worse from warmth and rest, 
relieved by moving about ; attended with restlessness and paralytic weakn 

Furuncle, Carbuncle. — In early stage before suppuration begins when 
there are tense tearing pains in and about the lesions, worse from warmth; 
general restlessness and prostration; erysipelatous looking areola. 

Leprosy. — Tubercle-like swelling of the skin, sharply defined, of brighl red 
color and hypersesthetic ; persistent thickening stiffness and hardness of the 
skin; aching of the extremities; restlessness, debility, sensitiveness to cold and 
wet; general aggravations from rest, at night, on beginning to move, tempo; 
rary amelioration from moving about. 

Erysipelas. — "Well defined swelling and dusky redness of the face, with 
puffy, swollen eyelids, scattered vesicles; with itching, burning and tense 
sensations, worse from warm applications; triangular dryness of tongue with 
fever; bruised, lame, aching pains in limbs and back, worse at night and from 
rest temporary relief from change of position, pressure and cool applications. 

Leucokeratosis buccalis. — Occasionally useful when there is a burning, 
smarting or conscious sensation of dryness or roughness of the affected surface 
and a frequent inclination to move the tongue about in the mouth; sensations 
relieved while eating and from increased flow of saliva. 

The general indications and modalities of rhus are to be always kept in 
view in selecting it as a remedy. These are not likely to be present in large 
per cent, except in those who are susceptible to the action of this drug, hence 
they often respond to remedial doses even when the eruption is not strictly 
characteristic. 

Ehus should never be administered to a patient for the first time lower 
than the sixth decimal, and the attenuation raised if any aggravation follows 
its use. Frequently the lower dilutions will be needed if the susceptibility to it 
is lacking or slight. 

RUMEX CRISPUS 

Yellow dock root causes an excessive irritability of the mucous membrane 
and the skin without evidences of primary inflammation. 

On the skin this action is evidenced by the sensations of excessive itching, 
stinging, prickling or burning, especially on the lower extremities. Scratching 



614 SABINA 

causes an eruption of papules, papulo-pustules, or wheals, and some relief of 
the sensations. The symptoms are worse from exposure of the skin to cool air, 
in undressing at night and on rising, and are relieved by warmth of bed and by 
scratching. 

Papular or papulo-pustular eczema with discrete lesions which appear 
more abundantly after scratching, especially if situated on the posterior aspect 
of the lower extremities, may occasionally present the characteristic indications 
for rumex noted above. Such cases are almost always chronic in course and 
marked by exacerbations in cold weather, indicating a participation of the 
peripheral nerves in the etio-pa'thology. Lichen simplex formerly designated 
this type of eczema, and a strong resemblance to prurigo may be sometimes 
observed; excoriated papules and an ill-defined pigmentation are not un- 
common. 

Piuritus. — Of legs, worse on calves. Excessive itching or stinging, worse 
from cold, better from warmth and somewhat from scratching. 

Urticaria, U. papulosa. — Chronic type, onset preceded by intense pruritus, 
antbscratching causes eruption to appear. Sensations increased by uncovering 
and cold, lessened by warmth. 

Prurigo. — Chiefly of legs, small papules or papulo-pustules increased by 
scratching. Pruritic sensations excited by cold, relieved by warmth. 

The curative dose of rumex must be varied in different cases. Probably 
the sixth decimal is more frequently employed. 



SABINA 

Sabina is a general irritant with a special affinity for the female genital 
organs, the urinary and intestinal tracts, the joints, and in less degree for the 
skin. The odor of the drug has been detected in the exhalations from the skin, 
but it is probable that its action on the surface tissues is largely reflex, and that 
it is adapted as a remedy only to such conditions. Comedones, macular, pap- 
ular, tubercular and pustular lesions have been noted : these were located almost 
exclusively on the face and genitals. Sensations of burning, pricking, sting- 
ing, stinging, soreness (on pressure), and itching are not usually marked, and 
may be confined to apex of lesions or hardly noticeable. Symptoms in general 
are worse in the open air. from motion, touch, and at night : better from 
warmth. 

Comedo. — Comedones that can be easily pressed out. in cheeks and about 
nose, in young women suffering from menstrual urinary, intestinal, rheumatic 
or neuralgic affections, with symptoms indicating sabina. 

Acne. — Pimples on cheeks and temples, with soreness, icorse on touch ; in 
association with Comedones with similar concomitants ; during pregnancy. 

Sabina acts best on the skin in the second or third decimal, rarely higher. 






SALICYLIC ACID 8ARSAPARILLA 615 



SALICYLIC ACID 

Salicylic acid and its salts act primarily on the vaso-motor centres and in 
Busceptible subjects cause hyperaemic and exudative lesions of the skin, rise of 
temperature and sensible perspiration. These and other disturbances are apt 
to bo attended with rheumatic' pains in extremities, dullness, weakness and 
sometimes vertigo and ringing in the ears. Macular, papular, nodular and 
secondary vesicular lesions are most common, and are attended with moderate 
itching or burning sensations. 

Erythema multiforme, E. nodosum.— Salicylic acid may lie indicated 
when the eruption suddenly appears on the face or upper extremities, preceded 
or accompanied with sweating and some of the above-named symptom-: E. 
witli secondary formation of vesicles in groups or rings ( E. iris) or bullae 
(E. bullosum). E. nodosum of the arms which develop rapidly will he gen- 
erally relieved by salicylic acid. 

The most prompt effect of salicylic acid may he generally obtained from the 
first or second decimal attenuation. 



SARSAPARILLA 

This drug deranges sensation and nutrition and produces symptoms resem- 
bling the specific poisons (syphilis and mercury) and other inflammatory 
affections of the mucous and cutaneous tissues without producing organic 
changes, except of a superficial nature. Its pains are often deep-seated and 
severe and are worse from dampness and at night. On the skin it has caused 
papular, nodular, vesicular, pustular and crusted lesions, generally located, but 
with a preference for the face, hands, anus, genitals and left •'<! : of trunk and 
hip. Sensations of pricking, itching stinging, burning and soreness may be 
felt in greater or less degree, and are apt to be worse from 5 to ; p.m. at night, 
from touch, change from warm to cold air. and for three days before the 
menses. 

Acne. — Papules and pustules on face and neck: worse on nose, forehead 
and chin, before menstruation, from constipation, after sexual excitement, 
seminal emissions, etc. Concomitant urinary affections, with pain after 
urinating, are suggestive indications. 

Alopecia prematura. — Falling out of hair, with sensitiveness of the scalp 
to touch, occipital headache: from late syphilis, abuse of mercury, etc. 

Onychia (paronychia). — Inflammation like a run-around around nail of 
index linger: ulcerations around ends of lingers, with pain on pressure; cut- 
Ting sensation under nails: chronic cases, especially when associated with 
soreness of the mouth (aphtha 1 , canker, etc.). or characteristic effects of sarsa- 
parilla. 



616 SEC ALE 

AY hen well indicated sarsaparilla does well in a medium attenuation, sixth 
decimal ; if no effect is obtained, a lower potency should be given. 



SECALE 

Ergot exercises a distinct influence on the cerebro-spinal nerves, and 
through the vaso-motor system produces characteristic chronic contractions of 
the muscular structures of the arteries, thus suspending the equilibrium of the 
circulation and resulting in coldness of the surface with a sense of internal 
heat which creates an intolerance to external warmth or covering. If the 
effect of ergot is continued the skin suffers from interference of nutrition, its 
functions from passive congestion, hemorrhages, induration, gangrene and sec- 
ondary inflammations. The surface of the skin is usually dry, its susceptibility 
diminished and paresthetic sensations of creeping, etc., in or under it are felt. 
Some general indications for ergot are debility, prostration, anxiety, a pale and 
sunken countenance, and emaciation, though the appetite and thirst may be 
excessive. 

Sclerema and cedema neonatorum, both rare and fatal affections of the 
new born, and due to retarded circulation in the capillaries from one cause 
or another, represent conditions in some respects similar to the effects of ergot. 
Its action should be studied in such cases and if found indicated it would prob- 
ably aid the cure of those amenable to treatment. 

Dermatitis gangrenosa infantum, probably due to the toxic effects of spe- 
cific bacteria, and in which simple lesions become hemorrhagic or gangrenous, 
thromboses occur in the neighboring capillaries and shallow or deep ulcers form 
singly or coalesce, furnish in some instances symptomatic as well as patho- 
logical indications for ergot. Attention should be always given to the general 
symptoms pointing to this remedy. 

Anaesthesia, Paraesthesia. — Of extremities and face when surface is cool 
and there is great intolerance of warmth. 

Purpura. — Large and small lesions; cool, dry skin with creeping sensations 
in or under affected parts; intolerance to covering or external heat; sense of 
relief from cool air; thin cachectic subjects or old people. 

Pemphigus. — In the old or debilitated, internal fever with cool surface at 
onset ; dislike to warmth ; blisters with bloody contents or leaving gangrenous 
spots. 

Symmetrical gangrene. — Diminished sensibility of the skin, bloodless, cool 
to touch, sometimes swollen. Ecchymoses and later symmetrical gangrenous 
spots. In the chlorotic or debilitated. Aggravations from warmth. 

Ainhum. — Secale may be indicated in this peculiar affection, the etiology 
of which is obscure. 

Ecthyma, Furuncle, Carbuncle. — In cachectic, debilitated or prema- 
turely old subjects, with dry, cool, shrunken skin : intolerance of warmth from 



SELENIUM SEPIA <''17 

covering and aggravations from warm applications; tendency to gangrenous 
changes of affected parts. 

Anthrax. — Fever with coolness of the surface and intolerance bo warmth; 
red spot with a purple or black centre, later bleb or vesicles with dark contents, 
dark red base and gangrenous appearance of lesion or adjacenl .-kin; crawling, 
burning or itching sensations, worse from warm applications. 

Leprosy. — Bullous or indurated lesions with anaesthesia of >km. especially 
Of the extremities ; probably useful in advanced stages when tin- skin is dry, 
shrunken and cool, fingers and toes atrophy and threaten to fall oil' and then; 
is greal intolerance to warmth, with Bense of relief in the open air. 

Secale acts well in a low attenuation, second or third decimal. In verv 
typical cases the higher attenuations are sometimes mosl effective. 



SELENIUM 

This metal in suitable form seems capable of inducing a general neuras- 
thenia, with partial emaciation and a tendency to neuralgic headaches, such 
as sometimes occur from exhausting disease or excesses. It has shown an 
affinity for the larynx, liver, male genital organs, and in a minor degree for 
the skin. An oily flux on the skin of the face and a few macular, papular, 
vesicular and pustular lesions have been recorded. Sensation and location are 
not characteristic. 

Seborrhoea oleosa. — Fatty appearance of skin of face: in the debilitated 
from previous disease; associated with genito-urinary disorders, etc. 

Comedo. — Comedones in association with an oily surface of the skin; 
dilated follicles plugged with mucous-like substance. 

Acne simplex. — Pustules which continue to inflame after discharge or 
expression of contents: with seborrhoea oleosa and comedo, and like general 
conditions. « 

Alopecia prematura. — Hair falls out on combing; with seborrhoea oleosa 
of scalp; in persons subject to headache, worse from strong odors, acids, tea or 
exposure to the sun; in the neurasthenic, with sexual weakness or perversions. 

Selenium should be given in the sixth decimal or higher, never lower. 



SEPIA 

This drug is believed to produce venous congestions, especially through the 
portal vessels. Whatever its mode of action general depression and torpidity. 
unhealthy secretions and enfeeblement of the vegetative functions follow, while 
the chief local effects are apparently expended on the mucous structures of the 
genito-urinary tract and on the skin. 

The skin of the face has a pale yellowish or waxy hue. sometimes with a 



618 SEPIA 

deeper yellowish or brownish saddle-like arrangement across the nose and out 
upon the cheeks, or similar roundish or oval spots elsewhere about the face and 
on the trunk. Vesicles or papules may appear on the face, occiput, back of the 
ears, in the flexors of the joints of the extremities and on the hands; pustules 
and ulcers are less common in the same region, bullae rarely form, become 
purulent, or exude a sticky fluid on rupture. ■ Sensations of itching, stinging 
and burning are most characteristic, but simple soreness or even an absence of 
sensory disturbance is not unusual. Symptoms, as a rule are worse morning 
and evening, after eating, at the menstrual period, and are temporarily better 
from being in the open air, from light touch, and from cold bathing. 

Sepia acts best on brunettes, especially women suffering from genito- 
urinary affections. 

Hyperidrosis, Bromidrosis. — Sweat on feet, worse on toes in morning; 
intolerable smell, on feet ; toes become sore, better from cold bathing, in debili- 
tated subjects who are bilious, dyspeptic, dull, irritable and discontented. 

Seborrhceic dermatitis. — Yellow saddle across upper part of cheeks and 
nose-^red, scaly roughness on face, nose,- forehead and scalp; "scaly eruption 
on the legs, or a dark, dusky redness of the skin :" in the torpid and depressed 
with sensitiveness of the skin to cold air. 

Comedo. — Many black pores on face ; with general indications for sepia. 

Acne. — Papules and pustules on face and scapulae, worse on chin and 
cheeks, with brownish areola; pustules on cheeks resembling chicken-pox, leave 
pits; with comedones, in young women, especially during pregnancy and the 
period of nursing. 

Alopecia prematura. — Falling out of hair, with pain on touch as if roots of 
hair were sore; in persons subject to sour perspiration of the scalp, neuralgic 
headache — from occiput to the eve. worse morning and evening. 

Lentigo. — Freckles which become more distinct or extend to covered parts 
after puberty, in young women with menstrual or uterine disorders : general 
depression and torpidity, pale or sallow tinge of lighter parts of skin. 

Chloasma. — Sepia is sometimes useful when indicated by general symptoms 
corresponding to its pathogenesis, and when the exposed parts of the skin 
have a yelloAvish hue. with areas of deeper staining, and approach symmetry 
in distribution. 

The general symptoms of such patients are apt to be worse at the beginning 
and end of day, when quiet, after sexual excess, and letter out of doors. 

Eczema in the flexures of the joints, at the occiput, behind the ears, on the 
face, either moist or dry and offensive may call tor sepia. In such case indica- 
tions for the drug are usually obtainable from some part of the mucous tracts ; 
in women aggravations occur before and during menstruation, and cold hands 
and feet (from uterine reflex) is a common condition. Efforts to relieve itch- 
ing by scratching often cause severe lmrning sensation in the skin. 

Ichthyosis may lie occasionally benefited by the action of sepia when there 
is an offensive odor of the affected skin and other indications for this remedy 
are found. 



BILICEA 619 

Rosacea. — Saddle-like, bluish or brownish distribution on nose and cheeks; 
papulo-pustules leaving pits. Yellowish or waxy hue of non-eruptive skin 
associated with genito-urinary ailed ions. Debility and genera] sensitiveni 

to cold air, while local symptoms are relieved in the open air. 

Herpes. — About mouth with considerable redness, burning or itching sen- 
sations. Associated with indigestion, with empty feeling in stomach and 
abdomen, great desire for food, or associated with genito-urinary affections, etc. 

Dermatitis herpetiformis. — Sepia should be studied as a remedy for the 
herpetic type of this disease when the cachexia, general symptoms and modali- 
ties correspond. 

Tinea circinata, T. tonsurans. — Round, circular or oval, reddish and 
scaly spots; itching, worse morning and night; dark sallow complexioned, 
feeble or torpid children with unhealthy or offensive secretions. 

Syphilis. — Humid primary sore with great puffiness of the surrounding 
tissues; cachectic appearance of the skin with mental dullness, depression or 
apathy; secondary squamous syphilides exhibiting a tendency to assume cir- 
cular outlines attended with the characteristic anaemia, waxy pallor, etc. 

Leprosy. — Yenons type, with dark skin becoming yellowish or waxy; men- 
tal and physical depression and torpidity; offensive secretions; puffiness of the 
skin with macular, tubercular, bullous or ulcerating lesions; hyperaesthetic and 
paresthetic sensations or other symptoms, often belter in the open air and from 
cold bathing. 

Lupus erythematosus. — Reddish or yellowish, well-defined, saddle-like 
patch over nose and on cheeks; especially in dark skinned, cachectic females 
with hepatic, venous or pelvic disorders and aggravations at the menstrual 
period. 

Verruca. — Large, hard seedy, flat or pedunculated warts on the face, neck. 
fingers or genito-anal regions of young, sallow brunettes, with a tendency to 
become pruritic or painful at the menstrual period, may he sometimes cured 
with sepia. 

Epithelioma. — Ulcer on lip or prepuce with a broad base, considerable 
puffiness of contiguous parts and burning, sticking or pricking sensations may 
indicate sepia when the systemic conditions and individual type resemble this 
remedy. 

Sepia should always be given in a high attenuation, rarely lower than the 
twelfth decimal. 

SILICEA 

Silicea disturbs the assimilation processes and slowly brings about defects of 
nutrition resembling some of the general and local manifestations of scrofula 
and rickets. The nervous system (probably from lack of nutrition) becomes 
irritable, sensitive, and is easily exhausted, Under such conditions there is 
little resistance of the tissues to suppurative and other morbid processes, and 
the surface structures are more likely to sutler from organic rather than 



620 



SILICEA 



functional affections, usually chronic in their course. The secretions of the 
skin may be increased or diminished, become offensive to smell or set up inflam- 
mation. 

Primary lesions maybe macular, papular, tubercular, vesicular or pustular, 
but a tendency to morbid growths or swellings, or ulcers, may exist and slowly 
assume a malignant type. Sensations of stinging, sticking, itching or burning 
are commonly felt with the eruption. There may be also great sensitiveness, 
bruised sensation, or crawling in the unaffected portions of the skin. Aggra- 
vations occur in the daytime and evening but not at night, and relief is gen- 
erally experienced from warm applications and warmth of room. 



Hyperidrosis, Bromidrosis. — Sweat at night, with loss of appetite ; on 
head only ; offensive on feet, soles and between toes, become sore when walking ; 
in irritable, sensitive persons, easily exhausted; putrid odor without sweat; 
sometimes useful for effects of suppression of habitual perspiration of feet. 

Acne simplex or indurata. — Papules and pustules on face and chest, 
worse on forehead in cold weather, better in warm weather; in the scrofulous, 
rachitic, sensitive or emaciated from general innutrition. 

Acne varioliformis. — Variola like pustules on forehead, occiput, or other 
parts of the body; when general symptoms correspond to silicea. 

Atrophia unguis. — Nails gray, dirty, as if decayed, when cut scattering 
like powder ; finger nails rough and yellow. 

Reedy nails. — Nails gray, etc., splitting into layers when cut. 

Onychia. — Sensations in tips of fingers as if suppurating; pain as if a 
panaritium would form ; itching cutting beneath nail of toe, pain beneath nail 
and stitches in it ; relief from warmth. 

Dermatitis calorica (burns). — Silicea is serviceable in burns of the second 
and third degree when the tissues fail to heal, suppurate or furuncular lesions 
develop on or near the sites first affected, with general hypersesthesia and 
aggravations by day. 

Vaccination eruptions. — When maturation or suppuration becomes the 
predominant feature of these lesions, especially in sensitive scrofulous subjects 
who cannot bear light touch near the affected parts, sleep uneasily at night and 
are irritable by day and are easily exhausted, silicea often brings about a rapid 
cure. 

Eczema occurring in the scrofulous or with other conditions of malnutri- 
tion, vesicular, vesiculo-pustular or crusted in form with offensive odor and 
pruritic sensations, worse during the day, may be frequently benefited by the 
action of silicea. Such eruptions are more often situated on the scalp, behind 
the ears, or on the arms, but location is not important in the presence of char- 
acteristic symptoms. In the less chronic cases offensive perspiration is a good 
indication, and in those of long duration enlargement or suppuration of the 
lymphatic glands is equally so. 

Prurigo. — Predominance of large papulo-pustules resembling lesions of 
varioloid, sensitive to touch and attended with itching, stinging or sticking-. 



BILK i:\ 621 

worse day and evening better from warm applications and warmth of room. 
Offensive odor of affected skin. 

Rosacea. — Redness of cheeks with large, sensitive, variola-like pustules, 
indolent in course, attended with sticking or burning, relieved by heat. 

Herpes zoster. — When lesions threaten to suppurate, arc extremi 
tive and attended with burning, sticking pains, worse in daytime, relii 
by warmth. Especially when pains continue after eruption begins to subside. 
Scrofulous subjects. 

Dermatitis herpetiformis. — Chronic cases in scrofulous subjects, or with 
constitutional symptoms resembling effects of ailicea. Multiform lesions, 
rounded groups or patches, preceded or attended with itching, burning or 
pricking sensations worse day and evening, better from warmth. Brownish 
pigmentations at sites of earlier lesions. 

Vitiligo has improved under the action of this drug. 

Impetigo contagiosa. — Veai co-pustular lesions on head or face, with offen- 
sive odor, especially in scrofulous or rickety children ; pruritic sensations worse 
in daytime, from cold, better from warmth. 

Ecthyma. — Pustular or other simple lesions very slowly changing to super- 
ficial ulcers, with little or no tendency to heal ; unusual sensitiveness of nervous 
system and of affected parts to pressure; poorly nourished subjects with ex- 
tremes of appetite. 

Furuncle, Carbuncle. — Boils and carbuncles which tend to increase in 
size, hecomc sensitive to touch and accompanied with general nervous ere- 
thism and other signs of mal-nutrition : sticking, burning and Btinging sensa- 
tions, worse from cold, better from warm applications and warmth of room. 
Late stage when reparative process is delayed. 

Elephantiasis. — In early stages for inter-current erysipelatous attacks at- 
tended with stinging, burning pains, somewhat relieved by warm applications; 
neurotic sensitive subjects who suffer from a variable degree of pain in parts, 
worse on first lying down at night and from cold, relieved by warmth; 
ciated with offensive perspirations. 

Scrofuloderma. — In children with poor assimilation who crave meat, gen- 
erally prefer cold food and are pale, nervous and irritable; swollen glands 
slowly tend to soften and suppurate and are usually sensitive; especially valu- 
able for the papulo-pustular scrofulide on the face and arms which leave pit- 
like scars. 

Syphilis. — Primary sore when actively inflamed, painful, depressed in 
centre and exuding a thin sanious fluid; poorly nourished, scrofulous indi- 
viduals, frightened, anxious and gloomy about themselves and the effects of 
the disease; secondary syphilides, persistent in course, with tendency of lesions 
to ulcerate, attack the bones and produce offensive discharges; general aggra- 
vations in daytime and early part of night, from told, some relief from 
warmth; especially in cases where free use of mercury lias failed to give aver- 
age benefit. 

Leprosy. — Macular, tubercular and ulcerating lesions, associated with 



*6 



622 SPIGELIA— STAPHYSAGRIA 

offensive secretions nervous sensitiveness; general aggravations from cold 
during the day and ameliorations from warmth. 

Silicea can be administered in medium or high attenuations. The sixth 
decimal is the best single attenuation. In malignant affections it may be 
necessary to use the first to third decimal, according to the effect observed. 



SPIGELIA 

Pink root acts almost exclusively through the peripheral nerves, causing 
marked disturbances of sensation, moderate derangement of nutrition and only 
slight inflammation. It shows an elective affinity for the fifth cranial nerve, 
the nerves of the trunk, especially the cardiac and intercostal branches. 
Sensations are neuralgic in type, with varying parsesthetic qualities (sticking, 
burning, boring, etc.) and tending to radiate in different directions. Aggra- 
vations occur from motion, cold, in. stormy weather, in the evening ; some 
relief is usually experienced from lying down, from warmth and pressure. 

Atrophia unguis, White nails. — Nails brittle and many white spots in 
them, with sticking, tearing, burning, etc. Sensations in fingers or toes; in 
neuralgic or rheumatic subjects with characteristic pains and modalities. 

Herpes zoster. — Pre-eruptive stage, involving branches of fifth nerve or 
the intercostal nerves, with pains radiating at times therefrom; burning, 
sticking and neuralgic pains; worse from motion, jarring, cold, and in the 
evening ; relieved by rest, warmth and pressure. During eruptive stage, when 
radiating pains continue with characteristic modalities. 

For the relief of its peculiar pains, spigelia does well in a comparatively 
high attenuation, the twelfth decimal, but when evidences of inflammation 
appear a lower- attenuation such as the second or third decimal is more 
effective. 

STAPHYSAGRIA 

This substance acts chiefly on the mucous membranes of the digestive and 
geni to-urinary tracts and upon the skin. The nervous system is affected by it 
to the extent of rendering the subject extremely sensitive to mental and phy- 
sical impressions. 

On the skin non-inflammatory lesions — papular and papillary growths may 
be excited, or chronic inflammatoiy papules, vesicles, pustules, and rarely 
ulceration may result from its action. Swelling of the neighboring lymphatic 
glands resembling scrofula or septic absorption may be noted. Secreting or 
crusted lesions are apt to give rise to a fetid or other offensive odor, and the 
sweat of other parts may be fetid also. The favorite locations are the face, 
scalp, neck, back of neck, ears, genitals and extremities. Sensations of itching, 
burning and crawling are felt in and about the affected skin. These are worse, 



STAPHYSAGRIA 888 

as a rule, in the evening and from touch, and arc temporarily relieved by 

scratching or changed in character or location. 

Bromidrosis. — Sweat of the odor of bad eggs ; on fed and genitals at night ; 
with sensitiveness of the skin to air; especially when associated with typical 
skin affections in other regions. 

Alopecia prematura. — Hair falls out ; with painful drawing sensations ex- 
ternally in places on head — worse on touch; itching, crawling, biting, worse on 
scratching; scales on scalp with fetid odor, or of sweat elsewhere; Bensitivenese 
of scalp to cool air and to all impressions. 

Eczema of the face, occiput, scalp, behind the ears, papulo-vesicular, pus- 
tular or crusted, will occasionally suggest this remedy. Great sensitiveness and 
unhealthy appearance of the parts even from external causes, such as pediculi, 
are further local indications for it. Generalized papular eczema (E. liche- 
noides) may present some of the above characteristic indications for this drug. 
The presence of spermatorrhoea from prostatic irritation, affections of the 
prostate alone, atonic disorders of the. stomach and stomatitis are special 
ciated indications. Mental and physical sensitiveness to all impressions are 
also important hints. 

Keratosis pilaris resembles objectively the goose-flesh appearance of the 
skin attributed to the action of staphysagria. The general symptomatology 
of this drug should be studied in the absence of other local indications. 

Lichen scrofulosus may be symptomatic-ally related to staphysagria. and 
should be compared with it in the study of a case of that disease. 

Pediculosis capitis. — In conjunction with its local use in aggravated cases, 
particularly when pruritic sensations are felt on distant parts of the surface, 
neighboring glands are swollen and there is an offensive odor from the scalp. 

Favus. — Yellowish crusts resting on a suppurating base or associated with 
pustular lesions of the scalp, an offensive odor of parts or secretions, loss of 
hair and swollen glands; sensitiveness to impressions and itching of non- 
affected skin; peevish and irritable subjects. 

Tuberculosis cutis. — Lupus, tuberculous or scrofulous ulcers at or about 
the muco-cutaneous outlets, with fetid odor bleeding from the affected mucous 
membrane, burning or crawling sensations, worse in the evening and relieved 
by cleansing and redressing of parts. 

Syphilis.- — Secondary moist lesions or later excrescences of the skin or 
mucous membrane with offensive odor, considerable sensitiveness and consecu- 
tive affections of the bones; irritable, sensitive, impressionable subjects who 
fear the worst results ; after abuse of mercury. 

The sixth decimal is a preferable attenuation, but needs to be varied to a 
lower or occasionally to a higher preparation. 



624 STILLINGIA— SULPHUR 



STILLINGIA 

This drug acts on the fibrous tissues, periosteum, lymph glands, respiratory- 
mucous membrane and sometimes consecutively on the skin, causing local 
inflammation characterized by free secretions.- The spirits are depressed, ap- 
prehensive, and the pains deep-seated as if in the bones or muscles; aggrava- 
tions occur in the afternoon, from motion and dampness. 

Scrofuloderma. — Enlarged cervical glands which tend to soften and ulcer- 
ate; attended with deep-seated pains, malaise and gloominess, worse in damp 
weather; ulcerations with profuse discharge, especially when associated with 
scrofulous catarrh of the nose, involving the bones, attended with soreness and 
a free purulent discharge. 

Syphilis. — Secondary eruption which tends to ulcerate, associated with 
ulcerations of the mouth or throat, specific catarrh, bone or muscular pains 
and enlarged glands. Later, gummatous periosteal or bone syphilis attended 
witli^mental gloominess, malaise and nocturnal pains. Symptoms or condi- 
tions generally worse afternoons, from motion and damp air. Valuable for in- 
tercurrent use in unpromising cases. 

Stillingia must be given in a low decimal attenuation or in tincture in most 
cases. 

SULPHUR 

Sulphur is a normal constituent of all protoplasm and its pathogenetic 
power is not limited to. any tissue or organ, but it acts pre-eminently on the 
skin, and may stand in therapeutic relation to any skin affection due to sys- 
temic conditions which primarily arose from causes originating either from 
within or from without the body. The earlier changes are probably nutritive. 
especially within the domain of the venous capillaries, and render the local 
processes irresponsive to ordinary stimuli. A tendency to ehronicity or recur- 
rence is, therefore, a feature in many cases of disease requiring this remedy in 
occasional or more frequent doses. No other drug is so commonly employed 
in dermatological practice (often abused), and none will repay more a careful 
analysis of its characteristics. 

On the skin sulphur is credited with producing all ordinary forms of pri- 
mary and secondary lesions and many varieties of sensor;/ disturbance. The 
more characteristic eruptions are papules, vesicles pustules, scales and crusts. 
Itching sensations may occur with or without eruptions ; sometimes the pruri- 
tus is voluptuous in character; often the lesions bleed easily and scratching 
is followed by soreness, burning or sticking sensations. 

Aggravations occur from warmth, particularly at night in bed, morning on 
waking, from bathing, after dinner, and from alcoholic stimulants. Some re- 
lief is felt during the day, and temporarily from walking and scratching. 



SULPHUR '>•-•■ 

Location of disturbance is not important, bul aitea of selection arc the occiput 
from car to ear, in the flexures of the joints, on the legs and the genito-anal 

region. Associated capillary venous engorgement, local or extended, is alwayi 
worthy of note. 

Sulphur subjects are nearly always irritable, depressed, thin and weak, even 
when the desire for food is excessive and frequently gratified. 

Hyperidrosis, Bromidrosis. — Sweat in axillae; offensive in axillae; of hands 
on palms; between fingers; about knees; worse at night or in morning on wak- 
ing; with burning or heal of some other parts of body. 

Seborrheic dermatitis. — Circumscribed red and scaly patches on various 
parts; sebaceous glands filled with products of inflammation appear more 
plain; itching, burning, etc., worse from warmth and bathing, especially when 
situated on the occiput (ear to ear) or the genito-anal regions. 

Comedo. — Comedones on nose; groups of black points like comedones on 
forehead, but cannot be squeezed out; dislike for bathing; impatient; good 
appetite, bul thin. 

Acne simplex or indurata. — Papules and pustules with red areola on lace, 
neck and shoulders; in thin, irritable subjects with dilated veins or capillaries; 
with harsh, rough skin; worse from alcoholic stimulants: disagreeable odor 
from skin, but disinclination to bathe; in chronic cases, rebellious to treatment. 

Alopecia prematura. — Hair falls out in morning on combing; with greal 
dryness and soreness of the scalp; with neuralgic headache: worse at night, 
from warmth, and on stooping; after suppression of eruptions; in persons 
very subject to eruptions of the skin or eruption alternating with other dis- 
orders; with pale ill appearance of face and red lips — after acute diseases. 

Onychauxis. — Nails thick, horny and misshapen: when general conditions 
or local eruptions indicate sulphur. 

Onychitis. — Sticking in root of nail in evening; pain in nail and ball of 
toe; pain inside of nail, with great soreness; tearing above nail and drawing 
in root of nail in evening; semi-lunar furrow across nails near their roots: with 
or after chronic affections. 

Chloasma. — Brownish spots on nose, worse in warm weather: in the poorly 
nourished who take abundant food, associated with capillary stasis Or varicosis', 
persistent in course, with a general aversion to washing or bathing. 

Erythema intertrigo. — Soreness in the folds of the skin, worse from 
warmth, bathing, stimulants, after eating and mornings; generally better 
from motion. 

Erythema calorica (chilblains). — On fingers with swelling of skin, cool 
to touch, in persons of sluggish circulation and subject to sweating of the 
bands, intolerable itching and tingling from warmth, changing to burning and 
soreness if scratched. 

Erythema multiforme. — Generalized red spots over body, persistent ap- 
pearance of new lesions, aggravation from warmth of bed. in cases which fail 
to respond to indicated drugs. 



626 



SULPHUR 



Vaccination eruptions. — In cases which have assumed a chronic course 
without regard to form of lesion, due to low state of nutrition; in thin, round- 
shouldered children, who dislike to stand, walk, bathe or go out of doors. 

Eczema of any form presenting the symptoms and modalities of sulphur 
will generally be benefited by its use. Commonly it is adapted to the papulo- 
vesicular, vesicular, vesiculo-pustular or squamous t)q)es which tend to pursue 
a chronic course. The most troublesome forms are found on the warmer re- 
gions of the skin, such as beneath the hair at the occiput, the folds, flexures- 
of joints, arms and genitals. Papular eczema generalized over the extremities 
and trunk, if not too chronic, often yields readily to this reined}'. 

In psoriasis sulphur is often helpful as an intercurrent remedj' when no 
response is apparent from another indicated drug. Occasionally it is indicated 
for frequent use by aggravations from warmth of bed, stimulants, a dislike for 
bathing, or rarely, by some pronounced constitutional symptoms. 

Keratosis palmaris et plantaris preceded or attended with evidences of 
venous engorgement of the skin, excessive sweating of the palms or soles or 
periodic burning sensations may be benefited by the administration of sulphur. 
ItTacts best in the early stages, but may be helpful intercurrently in cases of 
long duration. 

Dermatalgia. — Sticking or burning pains, worse from warmth, at night, 
especially when excited by stimulants or bathing. Hot palms and soles. 

Pruritus. — Of any region when aggravations occur at night from warmth 
of bed, bathing or washing, during rest, and some relief is obtained by moving 
about and from scratching; especially valuable for pruritus of vulva, perineum, 
anus or lower extremities. 

Urticaria. — Chronic or recurrent cases, always worse at night in bed, relief 
by day. Dread of a bath. 

Prurigo. — In weak, thin, round-shouldered subjects with good appetite; 
burning, itching or pricking sensations, irorsc from warmth and washing; 
relieved by motion and somewhat during daytime. Often useful as an inter- 
current remedy. 

Herpes. — About mouth and nose with itching and burning. Especially 
for the recurrent form in thin and weak subjects with excessive and frequent 
desire for food, sour eructations or other gastric discomfort alter eating. 

Atrophia maculosa et striata. — When there is capillary enlargement and 
constitutional conditions indicate sulphur. 

Scabies. — Chronic, neglected or recurrent cases; voluptuous pruritus, with 
burning or soreness after scratching and always worse from warmth : weak, 
thin, irritable subjects with swollen glands. 

Pediculosis. — Chronic or recurrent lousiness with great sensitiveness or 
soreness of the parts. To increase the resistance of the skin. 

Favus, Tinea circinata, T. tonsurans, T. barbae. — Chronic types in poorly 
nourished subjects with good appetites ; itching always worse from warmth, 
after bathing from stimulants and better when moving about. 

Furuncle. — Persistent appearance of boils, especially on dependent part? 



81 l.l'lll UK l M A( 1DI.M 627 

or in the car; stinging, smarting sensation*, worse from warm. moist applica- 
tions, somewhat relieved by moving about ; thin, Irritable subjects. 

Syphilis. — Persistenl secondary or tertiary Lesions, finally Leaving much 
pigmentation especially on extremities, with dilated veins and apparently due 
to venous stasis; aversion to bathing; poorly nourished subjects who take 
abundant food; glandular spelling; hard, dry, fissured patches on palms or 
soles which hum at night from warmth of lied and from washing. 

Lymphangiomata.- -Persistent tendency of dilated lymph vessels to ex- 
tend or multiply may suggest a study of sulphur as a possible remedy, particu- 
larly if some of its characteristics are present. 

Verruca, Clavus. — Painful or sensitive moisl warts or corns associated 
with localized sweating of the region involved may he sometimes cured with 
sulphur internally and oftener in conjunction with its local application. 

No one attenuation of sulphur can be named as the best. The twelfth 
decimal is good to begin with in a new case, but no one should give up a trial 
of this drug when indicated without changing to a lower or less often to a 
higher potency. 

SULPHURICUM ACIDUM 

Sulphuric acid induces a sort of cachexia manifested by emaciation weak- 
ness, a tendency to venous transudations into the mucous membranes and the 
skin, and sluggish or low types of inflammation. 

On the skin it may cause macular, papular, tubercular, pustular, ulcerative, 
scaly and crusted lesions, but it is especially related to lesions due to and at- 
tended with venous engorgement or hemorrhage at some part of their course. 
Location is not important, but the face, hands, extremities, buttocks and 
shoulders are the most common sites. Pruritic sensations may be prominent or 
absent. When present they are usually worse after midnight, from touch, and 
from taking warm food or drink. 

Erythema multiforme, E. nodosum. — Sulphuric acid is indicated in eases 
which also involve the mucous membrane, when the lesions look dark and 
hemorrhagic at an early stage, occurring in middle or later life, with burning 
or corrosive soreness, worse from touch and latter part of night, especially in 
weak or cachectic subjects. E. nodosum — add to above in tibial region, with 
burning, tension and great sensitiveness to touch as though suppuration was 
impending, unusual prostration, fretful and impatient. 

Dermatitis calorica (burns, frost bites). — Indicated in burns of second 
or third degree attended with great prostration, corrosive soreness, sensitiveness 
to touch, hemorrhagic or gangrenous appearance of portions of affected parts, 
when scars remain a deep red color and tender to touch. 

Chilblains or severe frost bites call for sulphuric acid when the parts are 
a dark purple color, sensitive, burn or feel as if scalded, and show a tendency 
to become gangrenous, and some general indications for this drug an- present. 



(i-28 



TARENTULA CUBENSIS— TELLURIUM 



Dermatitis traumatica. — When an ordinary injury of the skin inflames 
and becomes very sensitive, blackish and threatens to mortify, sulphuric acid 
will sometimes arrest the process. 

Dermatitis gangrenosa infantum among other forms of gangrenous in- 
flammations of the skin is very likely to present general and local indications 
for sulphuric acid. 

Pruritus. — Generalized, worse after midnight, in open air or in cold, wet 
weather. Especially in women at climacteric, associated with flashes of heat 
and general anaemia ; old people of both sexes who are fretful, impatient, etc. 

Purpura hemorrhagica. — Loss of dark blood from mucous outlets; bluish 
colored ecchymotic spots on forearms or elsewhere. In the cachectic and ema- 
ciated who are easily exhausted and feel sensations of tremor without trem- 
bling. 

The third decimal attenuation usually gives satisfaction in cases of skin 
disease calling for this drug. 



TARENTULA CUBENSIS 

Carbuncle, Anthrax maligna. — This spider poison is adapted only to the 
most severe types of inflammation and pain; deep purplish redness of the 
affected area with sharp stinging or burning pains; early and persistent pros- 
tration, diarrhoea or other symptoms of systemic infection. 

The sixth decimal attenuation is a suitable dose. 



TELLURIUM 

This metal in medicinal form acts prominently on the dermal tissues, 
giving rise to offensive perspiration, papular and vesicular lesions; the latter 
tend to assume circular or ring shapes and to spread at the periphery. Exuda- 
tions are irritating and are apt to become offensive. The most characteristic 
locations are back of the ears, occiput, at or near hair line, face, inner side of 
extremities and on any part subject to free perspiration. Sensations may vary 
widely; itching, pricking, smarting and burning are most common. Aggrava- 
tions occur after retiring at night, while at rest, in cold weather and from 
friction. 



Eczema. — Papular, vesicular or crusted in form, located on ears, back of 
ears at occiput or at other points of section named, persistent in course and 
extending to adjacent skin by contact of the discharge therewith, may be fre- 
quently cured with tellurium. Occasionally it will be found indicated for 
circular patches of eczema wherever located. 

Herpes. — After free and offensive perspiration, or critical sweats, soreness, 
pricking or itching, irorse from friction. 



TEREBINTHINA- THUJA 889 

Dermatitis herpetiformis. — Distinct herpetic type, with circular group* 
of vesicles on various parts. Preceded or attended with live or offensive sweat. 
Itching, pricking or smarting sensations, inns,' where skin perspires, at night 
in bed, from rest, in cold weather and on one side. 

Tinea circinata, T. tonsurans. — King shaped lesions on hairy or non- 
hairy parts; offensive odor from affected parts or of the perspiration; pruritic 
sensations, worse alter exposure to cold, while at rest and at night. 

Tellurium actswell on the skin in the sixth decimal and it is seldom 06 
sary to change the attenuation. 



TEREBINTHINA 

Oil of turpentine either by contact or through nerve irritation acts promi- 
nently on the mucous membranes (especially of the urinary tract) and on the 
skin causing' congestion, inflammation or hemorrhages. On the skin erythe- 
matous or hemorrhagic macules, papules and wheals may appear, and occasion- 
ally vesicles and pustules develop therefrom, all characterized by persistency. 

Sensations are often severe and consist of burning, smarting, stinging, ten- 
sion, soreness and itching which may persist after eruption has disappeared. 

Urticaria.— Papules or wheals situated on erythematous patches, localized 
or generalized, attended with pruritic sensations, which persist in the interval 
between the eruptive outbreaks or with unusually persistent lesions. Espe- 
cially when associated with urinary diseases or affectiofts of other mucous 
membranes. 

Purpura hemorrhagica. — Intestinal or urinary hemorrhages ami circum- 
scribed extravasations of blood into the skin. Persistent soreness of lesions 
or parts affected, which lesions remain unchanged or very slowly resolve, at- 
tended with general prostration. 

Herpes labialis. — Associated with affections of the respiratory or digestive 
tracts indicating turpentine. 

Only a low attenuation, first to third decimal is of service in skin diseases. 



THUJA 

■Arbor vitas acts chiefly on the mucous membrane and the skin, producing 
conditions which resemble the effects of locally inoculahle poisons, especially 
those which are prone to cause papillary hypertrophy. Admitting the etiolog- 
ical relation of early disease due to infection to late manifestations of a differ- 
ent nature, this drug may be found adapted to the cure or relief of a variety of 
cutaneous conditions, chiefly designated by Hahnemann as sycosis, and now 
believed to be due in whole or part to the immediate or remote effects of the 
action of bacteria. 



630 THUJA 

The skin lesions may be macular, vesicular, papular, tubercular, pustular, 
or squamous, but are very prone to develop from these or primarily warty or 
fungoid excrescences which bleed easily. Location is' not important, though on 
or about the head, genitals and arms are said to be characteristic. There may 
be an absence of sensory disturbance or any degree of itching, stinging, crawl- 
ing, sticking, biting, burning, etc. When present they are likely to be worse 
in the morning, evening, from rest, cold, stimulants, tobacco, washing, and bet- 
ter from warmth, open air, after appearance of menses or increase of other phy- 
siological discharges. This drug acts best on thin persons of the brunette type. 

Hyperidrosis, Bromidrosis. — Sweat on feet; inner side of thighs, geni- 
tals; worse on toes and at night", : with dryness of the hands; sour smelling 
almost every night. Has cured extremely fetid sweat of the feet, profuse 
sweating of perineum, and of uncovered parts (hands and head). 

Acne simplex and indurata. — Papules, tubercles and pustules on face and 
neck, worse between eyebrows; lesions bleed easily on rubbing or scratching; 
when secondary to other cutaneous affections; worse during menstruation 
or"ahy form of dissipation. 

Alopecia prematura. — Hair comes off of vortex, which is sensitive to 
touch ; scalp feels shrunken and hard on temples and forehead ; following vac- 
cination or other inoculable affections. 

Atrophia unguis. — Tearing in sides of nails; voluptuous itching between 
toes; with functional or inflammatory affections of the nerves of leg; when 
secondary to infectious diseases. 

Vaccination eruptions. — Thuja is the most common remedy for the vari- 
ous forms of eruption consecutive to inoculation with vaccine virus, and not 
infrequently for the more remote disturbances of the skin which appear to bear 
some relation thereto. It is especially adapted to the cure of vaccination erup- 
tions which become papillary or fungoid, bleed easily or profusely and are 
situated chiefly on the covered portions of the skin. Sensations and their 
modalities are not important in these cases. 

Tuberculin and anti-toxin eruptions are usually ephemeral in character. 
When persistent thuja should be considered as a remedy. 

Eczema calling for thuja can hardly be designated by lesions. It is more 
often vesicular or squamous, attending with itching, biting, tingling or burn- 
ing sensations and sensitiveness to touch; in chronic cases becoming hyper- 
trophic and little influenced by ordinary treatment. It is especially valuable 
in some cases of eczema with a history of syphilis some years previously (or 
in near ancestors), of aggravated or unusual vaccinia varicella, or other erup- 
tive disease attended with purulent formations or discharges from the skin 
or mucous outlets. In such cases other indications for the drug should be 
always sought for and considered in the choice of a remedy. 

In psoriasis probably due to early or hereditary effects of syphilis to effects 
of vaccination or secondary to other cutaneous disease thuja should always be 
considered as a probable remedy even in the absence of other indications for it. 



i l;'l HA C7REN8 ,;:: ' 

Ichthyosis hystrix lias been greatly benefited by this drug. 

Herpes progenitalis. — Persistent or recurrent, especially before nm 
relieved when flow begins. In either sex when outbreak is apparently excited 
by cold, stimulants, suppressed perspiration and attended with Btihging, 

sticking, itching or burning sensations, relieved by warmth, open air and free 
perspiration or other secretions. 

Pemphigus foliaceus, P. vegetans. — Painful vesicles and ulcers on the 
tongue; aphtha? and ulcers in mouth painfully sore to touch. Vesicular lesions 
which rupture and discharge a lymph-like fluid and have yellowish crusts. 
Fungoid excrescences which bleed easily on touch. Symptoms worse during 
rest, cold, alcoholic stimulants, tobacco, relieved by warmth and in the open 
air. 

Impetigo contagiosa, Ecthyma. — Pustular or ulcerative lesions following 
vaccination or other inoculable affections; thin, dark complex ioned and ill 
humored subjects; symptoms relieved by warmth and while in the open air. 

Lupus vulgaris, Tuberculosis verrucosa. — When dating from vaccination ; 
warty or fungoid lesions which bleed easily; symptoms generally worse from 
cold, tobacco, stimulants, washing, better from warmth and in the open air; 
mental depression and irritability. 

Syphilis. — Primary sore, with stinging, sticking or burning sensations; 
early or persistent secondary moist lesions on genito-anal regions or mucous 
membrane; exuberant, warty or cauliflower-like moist growths; dark, thin or 
depressed subjects; general or local aggravations in the evening, from cold, 
stimulants, tobacco, ameliorations from free action of the bowels, kidneys, 
warmth and open air. 

Rhinoscleroma. — Indurated swelling about nose (left wing) ; in indi- 
viduals who have been subject to inoculable eruptions at different times, near 
or remote. 

Verruca. — Moist, sensitive or bleeding warts of all shapes which appar- 
ently develop or continue to multiply by inoculation of the secretion or blood 
from earlier lesions of a similar or different nature. 

Verruga. — Papular or tubercular lesions developing in raspberry-like ex- 
crescences and tending to ulcerate. Probably curative when general symptoms 
and modalities resemble thuja. 

Thuja may be given in the sixth decimal or a lower attenuation. In dis- 
eases characterized by marked pathological change or growth the lowest attenu- 
ation is often required. 

URTICA URENS 

The stinging nettle taken internally produces similar effects on the skin as 
arise from its local application. These are mainly sensory and vasomotor in 
nature, and consist of circumscribed, oedematous swellings or nodules, bluish 
shining redness, and small vesicles, sometimes becoming confluent, with sensa- 
tions of heat, itching formication or numbness. An annual recurrence of 
symptoms is said to be an indication for this drug. 



632 VESPA 

Miliaria. — Heat in the skin of face, arms, shoulders and chest, with 
formication, numbness and itching; transparent vesicles filled with serum 
and looking like sudamina on upper part of body as far as navel; with more 
or less oedema of the skin; recurring every year; from idiosyncrasy to some 
article of food. 

Erythema multiforme. — General heat and fever, aching pains in arms, 
wrists and fingers, itching swellings, lumps and red spots over fingers, recur- 
ring annually. 

Dermatitis calorica (burns) .- — Urtica urens is occasionally indicated in 
burns of the first degree associated with greatly diminished or suppressed 
tirine ; considerable swelling of the parts which sting and burn and are some- 
what relieved by pressure. 

Pruritus. — Intolerable itching or formication of genitals or perineum, 
periodic or annual in occurrence, especially when due to or aggravated by some 
article, of ..food. 

Urticaria. — Generalized following, the use of shell-fish or some food for 
which there exists an individual idiosyncrasy. Intolerable itching and burning. 

^Angioneurotic oedema. — Bluish-white swellings of large size, attended 
with pruritic sensations, especially when traceable to the toxic effect of some 
food- or other substance. 

Herpes labialis. — Fever blisters attended with sensations of heat and itch- 
ing. Associated with catarrhal affections of the throat or stomach accom- 
panied with feverishness. 

TJrtica urens can be given in the third decimal attenuation for its effect on 
the skin in most cases to which it is adapted. 



VESPA 

f The poison of the wasp's sting acts on the peripheral nerves and peripheral 
nerve centres, causing vaso-motor disturbances, especially in the skin and 
mucous membranes.- The effects vary widely in degree according to the sus- 
ceptibility of the individual, as is likewise true of the toxins of disease. The 
pathogenesis of vespa is sufficiently similar to some vaso-motor affections of the 
skin to suggest it as a remedy in atypical cases. It has caused an outbreak on 
the skin of macules, papules, tubercles, wheals, swellings and secondary des- 
quamation, located chiefly on face, head, neck, hands, arms, front and back of 
chest, but can be excited anywhere by scratching; attended with moderate 
chills and fever, aching, burning, itching, stinging, soreness and tenderness. 
Sensations are temporarily relieved by bathing with vinegar and sometimes 
by cold water. 

Erythema multiforme. — Anomalous cases which resemble urticaria. 
Lentil-shaped, pinkish spots on hand and forearm, redness and swelling of 
ears and eyelids — redness extending to neck and head, with burning pain and 
tenderness, relieved by bathing with vinegar and salt or cold water. 



VINCA MINOR VIOLA TRICOLOR 

Furuncle. — Generalized boils or abscesses over the whole body canting 

emaciation; rapidly developing crops of boils attended with febrile symptoms; 
general aching, local stinging burning, soreness and tenderness, temporarilj 
relieved by bathing with vinegar or salt and vinegar solution. 

Vespa should bo given in the second, third or higher decimal attenuation. 



VINCA MINOR 

This drug has produced symptoms indicating irritation and passive hyper- 
emia of the surface tissues of the head and face, accompanied with disorders 
of secretions and sometimes consequent inflammation. 

Seborrheic dermatitis.— Of the scalp of infants, with offensive odor; itch- 
ing, ivorse from rubbing and scratching, sometimes relic red by warmth ; crusta 
lactea. 

•' Plica. — Matting of the hair; moist eruption on scalp, with vermin, espe- 
cially itching at night, with burning after scratching. 

Alopecia areata or prematura. — Heat in the scalp, with loss of hair; 
baldness, followed by a growth of fuzzy hair; with pricking, biting, crawling or 
itching sensations, worse from scratching; better from warmth of bed. 

Sero-purulent eczema of the scalp, matting the hair together, emitting 
foul odor or crusted forms on the scalp or face almost as offensive have been 
cured with vinea. 

Vinca should be given in a low attenuation, first to second decimal. 



VIOLA TRICOLOR 

• The action of this drug on the skin is like that of vinca, deranging the secre- 
tions and inflaming the tissues of the scalp and face. The eruption is acute in 
type and course, usually resulting in sero-purulent exudation which dries into 
gum-like crusts, crack and give exit to a tenacious yellow fluid to in turn 
solidify, and, if on the scalp, glue the hair together. Absorption of the morbid 
product often causes the neighboring glands to swell. The secretion of the 
urinary tract becomes changed so as to resemble in odor the urine of cats. 
Sensations of itching, stinging, biting, crawling or cutting are usually pro- 
nounced and are always worse at night. 

Eczema of the face or scalp with sero-purulent exudation, gum-like crusts. 
and intolerable pruritic sensation at night, which are somewhat relieved by 
scratching may be sometimes cured with viola tricolor. 

Impetigo contagiosa. — Groups of vesico-pustules on face or scalp drying 
into gum-like crusts which crack and give exit to added secretion; on scalp 



634 VIPERA— ZINCUM 

thick crusts matting the hair; aggravated cases occurring in winter, with 
itching at night; glandular swelling; cat-like odor of urine. 

Sycosis.— Early stage; sudden crops of closely situated pustules drying 
into yellowish, gummy crusts ; attended with itching, biting or crawling sensa- 
tions, worse at night and in cold weather. 

Viola acts best in a low attenuation, first or second decimal. 



VIPERA 

This serpent poison seems to act especially on the blood, lymph and their 
respective vessels causing conditions of localized congestion or inflammation 
and a peculiar sensitiveness to pressure of circulation in the affected parts, 
manifested by a bursting sensation. 

Purpura. — Livid or blackish spots on limbs or black petechia? with a sen- 
sitive skin, and a bursting sensation as though blood-vessels were over-distended 
when^parts are put in a dependent position. 

Furuncle, Carbuncle, Anthrax, Erysipelas. — Early congestive or inflam- 
matory stage of boils, carbuncles, etc. Situated on extremities or dependent 
parts, and in which a bursting or painful sensation is felt when the blood gravi- 
tates to the part, and relief is experienced by elevating the part involved. 

Lymphangioma. — Affections of the lymphatics which become somewhat 
painful when the lesions or vessels are most distended. 

Vipera should be given in the twelfth decimal attenuation every two or 
three hours to relieve the more urgent symptoms. 



ZINCUM 

Zinc acts on the cerebro-spinal centres and on organs and tissues through 
the connecting nerves ; general and local nutrition suffers, paralytic and pares- 
thetic symptoms are often prominent. On the skin offensive perspirations, 
macular, papular, vesicular and pustular lesions may appear from peripheral 
nerve irritation. Dilated capillaries or varicose veins may be concomitant and 
fissures secondary effects. Location of cutaneous disturbances may be general, 
but are more likely to be seated in the flexures of the joints, folds of the skin 
or in regions abundantly supplied with nerves. Sensations are marked and 
characteristic and may occur without objective symptoms; crawling, creeping 
(under or on the skin) , itching, burning, sticking are the most common. These 
are worse in the lower extremities and hands, in the evening and at night from 
wine, scratching (or the sensation appears at another point), and in the O'Den 
air; relief may be given by rubbing, pressure and on the appearance of sweat. 

Bromidrosis. — Offensive sweat on feet; sour smelling- with sticking sensa- 



ZINCUM 

tions or formication; worse at night, from vine; when other symptoms subside 
with appearance of sweat; with nervous depression from menial strain or Bexual 
excitement; with muscular twitchings at night. 

Acne. — Papules and pustules on face and shoulders, with dark bluish-red 
areola and pus also dark colored; worse from alcoholic stimulants; only in 
neurotic or anaemic cases with symptoms corresponding to zinc. 

Neurotic eczema occasionally calls for zinc by the presence of its charac- 
teristics. It is especially adapted to the anaemic neurotic, with fidgety, change- 
able disposition, in whom the sensory disturhanccs in the skin have preceded 
the outbreak of an eruption and the latter are located on the flexures. Paraly- 
tic constipation and general muscular twitching are good concomitants. 

Pruritus. — Of vulva or of legs and feet, preventing sleep. Crawling, bit- 
ing or itching sensations in the parts, worse after dinner, from wine, rest, heat, 
in evening and at night, better from rubbing, pressure and while eating. Mus- 
cular twitching. 

Prurigo. — Itching in non-eruptive as well as eruptive parts with shifting 
sensation from scratching. Varied pruritic sensations worse at night, from 
heat rest after meals, better from rubbing, while eating or when agreeably em- 
ployed. 

The sixth decimal is a suitable dose for most cases, but zinc occasionally 
acts better in a lower attenuation. 



INDEX 



INDEX 



Absorption, 17 
Acanthosis nigricans, 404 
Acarus scabiei, 28 i 
Achorion Schoenleinii, 299 
Acne adenoid, 88 
albidia, 82 
artificialis, 86 
atrophica, 91 
cachecticorum, 80, 371 
decalvans, 86, 110 
erythematosa, 239 
filaris, 91 

frontalis sot necrotica, 91 
hypertrophica, SO 
indurata, 85 
keloid, 86, 112 
lupoid. 91 
molluscum, SO 
punctata, 80 
rodens, 91 
rosacea, 80, 239 
scrofulosus, 371 
simplex, So 

syphilitica disseminata, 400 
ulcerosa, 91 
varioliformis, 91, 481 
vulgaris, S4 

symptoms of. 84 
etiology of, 80 
pathology of, 87 
diagnosis of, 87 
prognosis of, 88 
treatment of, 88 
Aconitum, 504 
Acquired leukasmus, 274 
Acrodermatitis perstans, 256 
Acrodynia, 258 
Acromegaly, 472 
Achromia, 274 

Actinomycosis of the skin, 325 
symptoms of, 325 
etiology of, 320 
pathology of, 320 
diagnosis of, 327 
prognosis of, 327 
treatment of, 328 



Acute circumscribed oedema, 229, 233 
idiopathic (edema, 2.;:s 
non-infla atoiy oedema, 233 

Addison's keloid, -71 

Adenoma. Is:: 

of the sebaceous glands, 483 
of the sweat glands, 182 
sebaceum, 483 
Aden ulcer, 353 
Agaricus, 50 1 
Agnus c. ist us. 505 
Ailanthus, 507 
Ainhum, 281 
Albinism, 27 4 
Albinismus, 274 
Aleppo evil, 352 
Aloes, 50G 
Alopecia, 101 
adnata. 101 
areata, 105 

symptoms of, 105 
etiology of, 107 
pathology of, 107 
diagnosis of, 108 
prognosis of, 108 
treatment of, 109 
circumscripta, 105 
pityrodes. 74 
prematura. 102 

symptoms of, 102 
etiology of, 102 
pathology of, 102 
diagnosis of, 103 
prognosis of, 103 
treatment of, 103 
presenilis. 102 
senilis, lo.i 
Alphos. 177 
Alumina, 500 
Ammonium carbonicum, 507 

muriaticum, 508 
Anacardium, 508 
Anesthesia, 221 

Analgesic paralysis with whitlow. 282 
Anatomical tubercle, 361, 478 
Anatomy. 1 
639 



040 



INDEX 



Andean waits, 502 
Angiokeratoma, 458 
Angioma, 457 

etiology of, 459 
pathology of, 459 
diagnosis of, 459 
prognosis of, 459 
treatment of, 459 
Angioma pigmentosum et atropliieum, 500 

serpiginosum, 458 
Angiomyoma, 450 
Angioneurotic oedema, 233 
Anidrosis, 60 

Animal parasitic diseases, 283 
Anthracinum, 509 
Anthrax, 347 

symptoms of, 347 
etiology of, 348 
pathology of, 348 
diagnosis of, 348 
prognosis of, 349 
^^ treatment of, 349 
benigna, 344 
maligna, 347 
simplex, 344 
Antimonium erudum, 509 

tartaricum, 511 
Antipyrine, 511 
Antitoxin eruptions, 144 
Apes mellifera', 294 
Apis, 512 
Area celsi, 105 
Argentum nitricum, 513 
Argyria, 123 
Arnica, 514 
Arsenicum album, 515 
bromatum, 519 
hydrogen, 519 
iodatum, 520 
Artificial eruptions, 142 
Aspergillus, 323 
Asteatosis, 70 
Asterias rubens, 521 
Atrophia cutis, 276 

maculosa et striata, 277 
senilis, 277 
unguis, 116 
Atrophoderma, 277 
neuriticum, 278 
pigmentosum, 500 
senile, 277 
Atheroma, 83 
Aurum, 521 

muriaticum. 521 



Bald tinea tonsurans, 305 
Banko-kerende, 281 
Barbadoes leg, 354 
Barber's itch, 305 
Barlow's disease, 236 
Baryta acetica, 522 

carbonica, 522 

iodata, 522 

muriatiea, 522 
Becquerel rays, 48 
Bedbug bite, 294 
Belladonna, 524 
Benign connective tissue growths, 449 

epithelial growths, 473 
Benzoic acid, 526 
Berberis, 526 

Biskra or Biseara button, 352 
Black-head, 80 
Blanching of the hair, 99 
Blastomycetes, 323 
Blastomycetic dermatitis, 322 
Blastomycosis, 322 
Blebs. 23 

Bleeder's disease, 236 
Blood-vessels of the skin, 12 
Bloody sweat, 65 
Body louse, 290 
Boils, 341 
Borax, 527 
Bovista, 528 

Bowditch Island ringworm, 318 
Bromidrosis, 62 
Brown-tail moth eruption, 153 
Bryonia, 529 
Bucnemia tropica, 354 
Bufo, 531 
Burmese ringworm, 318 

Cadmium sulfuratum, 531 
Caladium, 532 
Calcarea acetica, 533 

carbonica, 533 

rluorata, 534 

phosphorica, 535 

sulphuriea, 536 
Callositas, 473 
Callosity. 473 
Callus. 473 
Cancer. 4S6 

en cuirasse. 494 
Cancroid. 4S6 

ulcer. 4S7 
Canities. 99 

acquired, 99 



[NDEX 



641 



Canities, congenital, H!i 
etiology of, 99 
pathology Hi'. 99 
treatment of, 100 
Cannabis indica, 5:>7 
Cantharis, 539 
Uaraate, 324 
Carbo animal is, 539 
vegetabilis, 539 
Carbolic acid. 540 
Carbuncle, 344 
Carbunculus, 34 l 

symptoms of, 344 
etiology of, 345 
pathology of, 345 
diagnosis of, 34G 
prognosis of, 34G 
treatment of, 346 
CascadSe, 318 
Carcinoma cutis, 494 
pigmented, 494 
tuberose, 494 
(ai riou's disease, 502 
Causal treatment, 38 
Causticum, 541 
Chancre, 385 
chaps or chapping, 159 
Cheiro-pompholyx, 200 
Chelidonium, 542 
Cheloid, 451 
Chilblain, 127, 140 
Chinese ringworm, 318 
Chininum sulphuricum, 543 
Chionyphe Carteri, 329 
Chloasma, 120 

symptoms of, 120 
etiology of, 120 
pathology of, 121 
diagnosis of, 121 
prognosis of, 122 
treatment of, 122 
caloricum, 120 
gravidarum, 121 
symptomatic, 120 
toxicum, 120 
traumaticum, 120 
uterinum, 121 
Chloralum, 544 
Chromidrosis, 64 
Chromophytosis, 315 
Cicatrices. 26 
Cicatrix, 452 
Cicuta verosa, 545 
Cimex lectularius, 294 



Cist ii^. ."> 15 
Classifical ion, 52 

historical, 52 

author's, 54 

Clav US, 474 
( lenial i-. 540 

Clothes louse, 290 

Coca, .">Ui 

Cocculus, 547 
Cochin china leg, 354 
Colchicine, 5 18 
Colchicum, 5 is 

Cold sores, 243 

Colloid degeneration of the skin, 465 

Colloid milium, 4G5 

Colored sweat. 04 

Color of the skin, L5 

Comedo. SO 

symptoms, so 

etiology of, 80 

pathology of, 80 

diagnosis of, 81 

prognosis of, 81 

t reatmeni of, 81 

( 'omocladia, 54!) 

Condylomata lata. 397, 398 

Congenital achromia. 274 

baldness. 101 

leucasmus, 274 

leucoderma, 274 

leukopathia, 274 
Conglomerate suppurative perifollicu- 
litis. 113 
Conium, 549 
Copaiva, 550 
Corium. 4 
Corn. 474 
Cornu cutaneum, 47"> 

humanum, 475 
Cornus circinata, 551 
Corona veneris, 405 
Crab louse, 292 
Cretinoid oedema, 47 1 
Crotalus, 551 
Croton tiglium, 553 
frusta Iactea, 71 
( rusted ringworm. 297 
Crusts, 25 
Crutch itch, 321 
Culex pipiens, 294 
Cundurango, 553 
Cuprum arsenicosum, 554 
Curare, 554 
Cutaneous horn, 475 



A* 






H42 



INDEX 



Cutaneous horn, scrofuloderma, 370 

scrofulous gummata, 370 
Cutis testacea, 215 
Cyclamen, 555 
Cysticerus cellulosae cutis, 296 

Dandruff, 70 
Darier's disease, 470 
Delhi boil, 352 
Demodex folliculorum, 297 
Dengue fever, 258 
Dermanyssus avium, 295 
Dermatalgia, 221 
Dermatitis, 136 

ambustionis, 137 
artificialis, 153 
calorica, 137 

symptoms of, 137 

diagnosis of, 137 

prognosis of, 137 
' ^ treatment of, 138 
congelationis, 140 
contusiformis, 133 
exfoliativa, 187 

symptoms of, 187 

etiology of, 189 

pathology of, 189 

diagnosis of, 190 

prognosis of, 190 

treatment of, 190 
exfoliativa epidemica, 191 
exfoliativa neonatorum, 192 
gangrenosa, 194 
gangrenosa infantum, 195 

symptoms of, 195 

etiology of, 195 

pathology of, 195 

diagnosis of, 196 

prognosis of, 196 

ti'eatment of, 196 
herpetiformis, 250 

symptoms of, 250 

etiology of, 252 

pathology of, 252 

diagnosis of, 252 

prognosis of, 253 

treatment of, 253 
Kaposi, 500 
medicamentosa, 142 
mycotica, 321 
papillaris capillitii, 112 
repens, 255 
Rontgen ray, 141 
traumatica, 141 



Dermatitis venenata, 152 
Dermatolysis, 450 
Dermatoniycosis furfuracea, 315 
Dermatosclerosis, 268 
Dhobie itch, 321 
Diabetic gangrene, 194 
Diagnosis, 34 
Diathetic affections, 156 

classification of, 55 
Digitalis, 555 

Diseases of cutaneous appendages, 60 
classification of, 54 

of the hair and hair follicles, 92 

of the nails, 114 

of the sebaceous glands, 70 

of the sweat glands, 60 
Dissection wounds, 350 
Distichiasis, 95 
Distoma hepaticum, 296 
Dracunculus medinensis, 295 
Drug eruptions, 142 

aconite, 143 

ailanthus, 143 

amygdala amara, 143 

anacardium, 143 

antimonium crudum, 143 

antimonium tartaricum, 143 

antifebrine, 143 

antipyrine, 143 

antitoxin, 144 

apium virus, 144 

arsenicum, 144 

arum, 144 

aunim metallicum, 144 

belladonna. 144 

benzoic acid, 144 

borax. 144 

bromine and its salts, 144 

brvonia. 145 

calcarea carbonica. 145 

calcium sulphide. 145 

cantharides, 145 

capsicum. 145 

carbolic acid. 145 

chloral hydrate. 145 

chloralamid, 145 

chloroform, 14"> 

chrysarobin. 145 

cieuta virosa. 146 

cinchona, 146 

conium, 146 

condurango, 146 

copaiba and cubebs, 146 

creosote. 146 



INDKX 






Drug eruptions, digitalis, 140 

dulcamara, 14(! 

('111)11011)111111 iind other iv-mis, 140 

folium iodid, 140 

graphites, 148 

Hydrastis, 14(i 

hyosoyamus. 147 

iodine and its compounds, 147 

iodoform. 147 

ipecac. 147 

iris versicolor, 147 

jaborandi or pilocarpine, 147 

ledum. 147 

lyeopodium, 147 

mercury and its salts, 147 

mezereum, 147 

nitric acid, 147 

mix vomica and strychnia, 148 

oil of sandalwood, 148 

olium morrhuse, 148 

olium ricini, 148 

opium and its alkaloids, 148 

phenacetine, 148 

phosphorus and phosphoric acid, 148 

piper methysticum, 148 

plumbum and its salts, 148 

Pulsatilla nigricans, 148 

potassium chlorate, 148 

ranunculus bulbosus, 148 

rhubarb, 140 

santonin, 149 

salicylic acid and salicylate of 
soda. 149 

staphysagria ,149 

secale, 149 

staphysagria, 149 

stramonium, 149 

sulphonal, 149 

tanacetum (oil of tansy), 149 

thuja, 149 

turpentine (terebene), 149 

valerian, 149 

veratrum viride, 150 
Dulcamara, 556 
Dysidrosis, 2G0 

Echinococcus, 20d 
Ecthyma, 334 

symptoms of. 334 

etiology of, 335 

pathology of, 335 

diagnosis of, 335 

prognosis of, 335 



Ecthyma, treatment of, 335 
Eczema, 156 

Bymptoma of, 166 

etiology Of, 102 

pathology of, lii.'S 

diagnosis of, 164 

prognosis of, 166 

treatment of, 168 
ani. 160 
aiirium. 160 
capitis, 159 
circumscriptum, 157 
condensed repertory for, 175 

lesions, 175 

course or type of, 170 

li C it ion of, 170 
aggravations of. 170 
ameliorations of, 177 

epidemic, 191 

erythematosus), 156 

exfoliativa, 157. 159 

facei, 159 

fissum, 150 

genitalium, 100 

hypertrophicum sou tuberosum, 498 

impetiginodes, 15$ 

intertrigo, 157 

labiorum, 100 

madidans, 157 

mammae, 1G0 

marginatum, 303 

nariuin, 160 

neurotic, 161 

of the extremities, 101 

palmare, 100 

palpebrarum, 100 

papillosum, 158 

parasitic, 101 

pustulosum, 158 

rhagadiforme, 159 

rubrum. 157, 158 

sclerosum, 160 

seborrhceicum, 73, 101 

squamosum, 157. 158 

umbilici, 101 

unguium. 161 

varieosuni. 101 

verrucosum, 161 

vesiculosum, 157 
Eczematous folliculitis. 161 

epitheliomatosis of the nipple. 488 
Effects of existing disease. 30 

Electricity, 44 



644 



INDEX 



Elephantiasis, 354 

symptoms of, 354 
etiology of, 356 
pathology of, 356 
diagnosis of, 357 
prognosis of, 357 
treatment of, 357 
Arabum, 354 
Ciraccorum, 429 
Indica, 354 
telangiectodes, 356 
Elephant leg, 354 
Endemic boils, 352 
Equinia, 442 

symptoms of, 442 
etiology of, 443 
pathology of, 443 
diagnosis of, 443 
prognosis of, 443 
treatment of, 443 
Epkelides, 119 
Epidemic eczema, 191 
erythema, 258 
pemphigus, 332 
skin disease, 191 
Epidermis, 5 
Epidrosis cruenta, 65 
Epithelial cancer, 486 

carcinoma, 486 
Epithelioma, 486 

symptoms of, 486 
etiology of, 488 
pathology of, 489 
diagnosis of. 489 
prognosis of, 490 
treatment of, 490 
adenoides cysticum, 482 
contagiosum, 481 
Erectores piloram, 15 
Eruption, 27 
Eryngium aquaticum, 
Erysipelas, 444 

symptoms of, 
etiology of, 445 
pathology of, 445 
diagnosis of, 446 
prognosis of, 447 
treatment of, 447 
Erysipeloid, 447 
Erythema, 124 
ab igne, 126 
caloricum, 126 
circinatum or annulare, 131 
exudativum, 130 



557 



444 



Erythema fugax, 127 
gangrenosum, 127 
gyratum, 131 
induratum, 383 
indure des serofuleux, 383 
indure serofuleux, 370 
infantilis, 127 
intertrigo, 124 
iris, 132 
keratodes, 211 
lseve, 127 
marginatum, 131 
medicamentosa, 127 
multiforme, 130 

symptoms of, 131 

etiology of, 133 

pathology of, 133 

diagnosis of, 135 

prognosis of, 136 

treatment of, 137 
neonatorum, 124 
nodosum, 133 
papulation, 131 
paratrimma, 126 
pernio, 127, 140 
pudoris et iracundiae, 127 
roseola, 127, 128 
scarlatiniforme, 127 

symptoms of, 127 

etiology of, 129 

pathology of, 129 

diagnosis of," 130 

prognosis of, 130 

treatment of, 130 
scarlatiniforme desquamatieum, 128 
simplex. 124 
syphiliticum, 391 
traumaticum, 126 
tuberculatum or tuberosum, 131 
urticatum, 132 
vacciniforme, 127 
venenatum, 127 

vesiculosum and bullosum, 132 
Erythrasma. 320 
Etiology, 27 

predisposing causes, 2S 

direct causes, 32 
Eupliorbium, 557 
Excessive sweating, 61 
Excoriations. 2.3 

Fagopyrum. 5.37 
Farcy, 442 
Fattv tumor. 4.5-3 



INDEX 



64f> 



Favus, 297 

symptoms of, 2H7 
etiology of, 298 
pathology of, 298 
diagnosis of, 300 
prognosis of, 301 
treatment of, 301 
[upinosus, 297 
of the nails. 298 
of the non-hairy parts, 298 
squa rrosus, 297 
Feigned erupt ions, 153 
Fetid sweat, 62 
Fever blisters, 243 
Fibroma, 449 

fungoides, 498 
lipoinatoJes, 453 
molluscum, 449 
pendulum, 450 
Fig wart, 47S 
Filaria medinensis, 295 
Fish skin disease, 213 
Fissures, 25 
Flea bite, 293 
Fluoricum acidum, 558 
Folliculitis barbae, 336 

decalvans, 110 
Folliculite epilante, 110 
Fragilitas erinium, 95 
Framboesia, 440 
Freckles, 119 
Frostbite, 140 
Fungoid dermatitis, 498 
Fungus foot of India, 328 

growth in the nail, 115 
Furuncle, 341 
Furuneulus, 341 

symptoms of, 341 
etiology of, 342 
pathology of, 342 
diagnosis of, 343 
prognosis of, 343 
treatment of, 343 
orientalis, 352 

Gafsa button, 352 

General features of lesions, 26 

Giant swelling, 233 

Glanders, 442 

Glossy skin, 278 

Granula roseola, 301 

Granuloma fungoides, 498 

Graphites, 559 

Grayness of the hair, 99 



Grutum, B2 

( iuineo woi m, 

Gummatous ulcer, ins 

Gune, 318 

(iui ia rosac sa, 239 

Hsmatangioma, 158 
I hematidrosis, 
Hsematomata, 236 
Hemophilia, 236 
llaiis. s 

Harvest bug bite, 294 
Head louse, 288 
Heat regulation, 17 
Helleborus niger, 561 
Hepar Bulphur, 561 
Herpes, 242 

circinatus, 132. 242, 303 

desquamans, 318 

facialis. 243 
febrilis, 243 
gestationis, 250 
iris. 132. 242 
labialis, 243 
preputialis, 214 
progenitalis, 244 
tonsurans, 2 12, 303 
tonsurans barbs, 305 
tonsurans maculosus, 198 
zoster, 245 

symptoms of, 245 
etiology of, 24s 
pathology of, 248 
diagnosis of, 24!) 
prognosis of, 249 
treatment of, 2)9 
Hidebound disease. 268 
High tension and frequency currents, 49 
Hirsuites, 92 
Hives. 229 

Honeycomb ringworm, 297 
Hydradenitis suppurativa, 69 
Hydrastis. 5(14 

Hydroa, 259 

bulleux, 259 

puerorum, 259 

vacciniforme, 259 

vacciniforme sen eestivale, 259 

vesiculeux, 259 

bullosus, 250 

herpetiforme, 250 
Hydroeotyle. 565 
Hydrocy stoma, (it! 
Hydrosis, (il 



646 



INDEX 



Hydrosis, pathology of, 206 

Hygroma colli, 402 

Hyoscyamus, 5C6 

Hyperesthesia, 220 

Hypericum, 567 

Hyperidrosis, 61 

symptoms, 61 
etiology of, 61 
pathology of, 61 
treatment of, 62 

Hypertrichosis, 92 

etiology of, 92 
treatment of, 93 

Hypertrophic scar, 451 

Hypertrophy of the hair, 92 
of the nail, 114 

Hysterical gangrene, 194 



Impetigo parasitica, 332 

rodens, 401 

simplex, 330 

sparsa, 330 
India ringworm, 318 
Induration of the cellular tissue of the 

new born, 217 
Indurato tela? eellulosa, 217 
Inflammation involving the nail, 118 
Inflammatory fungoid neoplasm, 498 
Insect bites, 293 
Instruments, 42 
Internal therapeutics, 504 
Intertrigo, 124 
Iris versicolor, 568 
Itch, 283 
Ixodes ricinus, 294 



Ichthyosis, 213 

symptoms of, 213 
etiology of, 215 
pathology of, 215 
diagnosis of, 216 
prognosis of, 216 
treatment of, 216 

acquired, 215 

congenita, 214 

follicularis, 476 

hystrix, 215 

linguae, 215, 484 

nigricans, 214 

nitida, 214 

palma?, 214 

palmaris et plantaris, 211 

sauroderma, 214 

scutulata, 214 

sebacea, 215 

sebacea cornea, 476 

serpentina, 214 

simplex, 213 

vera, 213 
Idiopathic affections, 119 

classification of, 55 
Idrosis, 61 
Ignis sacer, 245, 444 
Impetigo, 330 

contagiosa, 332 

symptoms of, 332 
etiology of, 333 
pathology of, 333 
diagnosis of, 333 
prognosis of, 334 
treatment of, 334 

herpetiformis. 254 



Jaborandi, 509 
•Jacob's ulcer, 487 
•ligger bite, 293 
Juglans einerea, 569 
regia. 570 

Kali bichromicum, 571 

bromatum, 572 
carbonicum, 573 
iodatum, 574 
muriaticum, .575 
phosphoricum, 570 
sulphurieum, 577 
Kalmia. 578 
Kelis. 451 
Keloid, 451 
Keratoma, 211 

Keratodermia erythematosa symmet- 
rica. 211 
Keratosis follicularis. 476 

palmaris et plantaris, 211 
symptoms of, 211 
etiology of, 212 
pathology of. 212 
diagnosis of, 212 
prognosis of, 212 
treatment of. 212 
pilaris. 209. 213 

symptoms of. 209 
etiology of. 209 
pathology of. 209 
prognosis of. 210 
treatment of. 210 
pigmentosa. 478 
senilis, 210 



INDEX 



in; 



lierion, 304 

Kraurosis vulva', 278 

rlreosotum, 579 

Lachesis, 580 
La rosa, 257 
La I'ita, 318 
Ledum, 581 
Lentigo, 11!) 

maligna, BOO 
Leontiasis, 429, 455 
Lepothrix, 98 
Lepra. 177, 429 
[talica, 257 
Leprosy, 42!) 

symptoms of, 430 
duration of, 430 
etiology of, 435 
pathology of, 435 
diagnosis of, 430 
prognosis of, 437 
treatment of, 437 
anaesthetic, 430, 433 
mixed form of, 430, 435 
syphilitic, 430. 435 
tubercular. 430, 431 
Leptus autumnalis, 294 
Lesions, si/.c and shape. 27 
Leukoderma, 273 

acquisitum, 274 
Leucokeratosis buccalis, 484 
Lenkopathia, 274 
unguium, 117 
Leucoplakia, 4S4 
Lichen, 200 

circinatus, 200 
circumscriptum, 15S. 382 
eczematodes, 200 
neuroticus, 200 
pilaris. 200. 209 
planus. 205 

symptoms of, 205 
etiology of, 206 
pathology of, 206 
diagnosis of, 200 
prognosis of, 207 
treatment of, 207 
planus corneous. 200 
planus hypertrophicus, 206 
planus verrucosus, 206 
psoriasis, 201 
rubra. 201 

symptoms of, 201 
etiology of, 203 
pathology of, 203 



Lichen rubra, diagnosis of, 203 

prognosis of, 201 

treatment of, 20 1 
ruber acuminal us, 20] 
ruber moniliformis, 203 
ruber inuiol ions, 203 
ruber papulosus, 21)1 
ruber pilaris. 201 
ruber planus, 2115 

ruber rugosus, 202 
ruber Bquamosus, 202 
Bcrofulosorum, 382 
scrofulosus, 382 

symptoms of, 3s^ 
etiology of, 382 
pathology of, 382 
diagnosis of, 383 
prognosis of, 383 
treatment of, 383 
simplex, 158, 200 
strophulosus, 200 
tropicus. 07. 201) 
urticatus. 132, 200 
Lineae albicantes, 277 
Lioderma essentialis cum melanosi 

telangiectasia. 500 
Lipoma. 455 
Liver spots. 120 
Local asphyxia. 2Sll 
Lombardy erysipelas. 257 

leprosy. 257 
Lota. 325 
Lousiness. 288 
Lu"s venera. 38 I 
Lupoid sycosis, 338 
Lupus crust osus, 36 I 

diffusus radians. ;;ii i 
disseniinat Us, 365 
elephant iat icus, 363 
elevatus. 303 

erythematoides of Leloir, 364 
erythematodes, 466 
erythematosus, 466 

symptoms of, 466 
etiology of, 407 
pathology <>f. 467 
prognosis of. |i;s 
diagnosis of. 168 
treatment of. 168 
e\foliati\ us. :)(;:; 
exulcerus, 364 
librosus. 3(1°) 
hypertrophicus, 303 
maculosus, 303 
nodosus, 363 






648 



INDEX 



Lupus, non-exedens, 363 

non-ulcerosus, 3C3 

oedematosus, 303 

of extremities, 3C5 

of face, 305 

of genitals, 365 

of mucous membranes, 366 

of trunk, 365 

phagedenicus, 364 

papillosus, 363 

planus, 363 

psoriasiforme, 363 

selerosus, 363 

sebaceous, 460 

serpiginosus, 303 

sore, 364 

superficial is, 364, 466 

tuberculatus, 303 

tumidus, 303 

verrucosus, 301 

vorax, 304 

vulgaris, 303 

symptoms of, 363 
etiology of, 360 
pathology of, 367, 373 
diagnosis, 308 
prognosis, 369 
treatment of, 376 
Lycopodium, 582 
Lymphangiectasis, 461 
Lymphangiectodes, 462 
Lymphangioma, 401 

tuberosum multiplex, 462 
Lymphangio-myoma, 450 
Lymphatics of the skin, 12 
Lymphodermia permieiosa, 498 
Lymph orrhagica pachyderma, 401 
Lymph scrotum, 357 

Macrocheilia, 462 
Macroglossia, 462 
Macula 1 cerulese, 202 
Macules, 20 
Madura foot, 328 
Malabar itch, 318 

ulcer, 353 
Mai del pinto, 323 

Malignant connective tissue growths, 
495 

epithelial growths, 486 

papillary dermatitis, 48S 

pustule, 347 
Malleus, 442 
Malum perforans pedis, 279 



Mamillaris maligna, 488 

Manganum, 584 

Manila itch, 321 

Marie's disease, 472 

Matted hair, 100 

Mechanical treatment, 40 

Melanoderma, 120 

Melanosis lenticularis progressiva, 500 

Melanotic whitlow, 496 

Mentagra, 336 

parasitica, 305 
Mercurius biniodidus, 587 

corrosivus, 588 

vivus, 585 
Mezereum, 588 
Microsporon Audouini, 306 

furfur, 317 

minutissimum, 321 
Miliaria crystallina, 66 

papulosa, 67 

rubra. 07 

symptoms of, 67 
etiology of, 08 
pathology of, 68 
diagnosis of, 03 
treatment of, 68 

vesiculosa, 67 
Miliary tuberculosis, 359 
Milium, 82 
Mole, 463 
Molluscum contagiosum, 481 

epitheliale, 481 

sebaceum, 481 
sessile, 4S1 
verrueosum, 481 
pendulum, 449 
simplex, 449 
Monilethrix, 97 

Moniliform or beaded hairs, 97 
Morbus elphus, 354 

gallicus, 384 

maculosus Werlhoffi, 235 
Morphoea, 271 
Morvan's disease. 282 
Mother's marks. 458 
Moth patches, 120 
Mucous patches, 397 
Multiple benign cystic epithelioma. 4S2 

benign tumor-like new growths. 465 

cncheetic gangrene. 195 

fungoid papillomatous tumors, 498 

gangrene. 194 

sarcoma cutis, 49S 
Muriaticum acidum. 590 



INDIA 



049 



Muscles ni' iln> Bkin, 14 
Mycetoma, 328 
Mycosis fungoidea, 498 

symptoms ofj 198 

etiology of, 499 

pathology ni. V.)'.) 

diagnosis of, 199 

prognosis of, 199 

treatment of, 499 
microsporina, 315 
Myeloma cutis, 498 
Myelosyringosis, 282 
Myoma, 156 
Myo-fibromata, 156 
Myringomycosis, .323 
Myxoedema, 471 

Nanus araneus, 458 

flammeus, 457 

lipomatodes, 4.").") 

lupus, 458 

nervosus, 40.3 

pigmentosus, 40.3 

pilosus, 40.3 

sanquincus, 457 

vasculosus, 457 

verrucosus, 403 
Nsevi vasculaires et papillaires, 483 
Nails, 9 
Natal sore, 352 
Natrum arsenicatum, 592 

muriaticum, 592 

phosphoricum, 595 

sulphuricum, 590 
Neoplasmata, 449 
Nerves of the skin, 1.3 
Nettle-rash, 229 
Neuralgia cutis. 221 
Neurofibroma, 449 
Neuroma, 450 

plexiform, 457 
Neuropathic papilloma, 480 
Neuropathic affections, 220 

classification of, 56 
New growths, 449 

classification of, 58 
Nitricum acidum, 596 
Noli-me-Tangere, 487 
Nux moschata, 598 

vomica, 599 

Objective symptoms, 20 
(Edema neonatorum, 218 



(Edema, aymptonu of, 2ls 

etiology of, 218 

pal bology of, 21 8 

diagnosis of, 219 

prognoaia of, 219 

treatment of, 219 
of t he new born, 2 I s 
i Meander, 599 
Onychat rophia, I Mi 
Onychauxis, 1 14 

Bymptoms of, 1 14 

et iology of. 1 14 

prognosis of, 1 15 

i reatmenl of, 1 15 
Onychia, 1 is 

maligna, I is 
Byphilitic, lis 
formalin, 1 1 B 
( Inychomycosis, 1 15 
Operative procedures, 42 
Opium, coo 
Oriental boil, 352 
Oroya fever. 502 

Osmidrosis, 02 
Osmium, 60] 
Otomycosis, 323 

Pachyacria, 472 

Pachydermia, 35 l 

Paget's disease of the nipple, 488 

symptoms of, 4SS 

etiology of, 488 

pathology of. 489 

diagnosis of, 489 

prognosis of, 490 

treatment of. 490 
Papillary layer of the corium, 4 
Papilloma cutis, 4S0 
Papules, 21 
Paresthesia, 221 

Parakeratosis variegata (Unna), 20S 
Parasitic affections, 283 

classifical ion of. 57 

SyCOSis, 305 

Paris quadrifolia, 001 
Partial albinism, 274 
Patches, 26 

Pathogenetic therapeutics, 39 
Pediculosis, 288 

capitis, 288 

corporis, 290 

pubis, 292 
Pediculus vestimenti, 290 
Pellagra, 257 



•, 



C > 



** 



r < 



650 



INDEX 



Peliosis rheumatica, 236 
Pemphigus, 261 

symptoms of, 261 
etiology of, 265 
pathology of, 266 
diagnosis of, 266 
prognosis of, 267 
treatment of, 267 
acutus, 263 
benignus, 262 
chronic, 261 
circinatus, 264 
circinatus bullosus, 250 
contagiosus tropicus, 264 
diphthericus, 262 
disseminatus, 261 
foliacens, 264 
gangrenosus, 195, 262 
hemorrhagicus, 262 
hystericus, 264 
malignus, 262 
.neonatorum, 263 
pruriginosus, 250, 264 
serpiginosus, 264 
solitarius, 262 
vegetans, 262 
vulgaris, 261 - 
Perforating ulcer of the foot, 279 
Perifolliculitis tuberculosa, 382 
Pernio, 140 
Peruvian warts, 502 
Petroleum, 601 
Phagedena tropica, 353 
Phosphorescent sweat, 65 
Phosphorus, 603 
Phosphoricum acidum, 605 
Phototherapy, 46 
Phthiriasis, 288, 290 
Phthiriasis pubis, 292 
Physiological treatment, 39 
Physiology, 16 
Phytolacca, 606 
Picricum acidum, 607 
Piebald skin, 274 
Piedra, 98 

Pigmentary mole, 463 
Pili annulati, 97 
Pinta disease, 323 
Pinto disease, 323 
Pityriasis capitis, 74 

maculata et circinata, 198 
nigra, 120 
pilaris, 209 
rosea, 198 



Pityriasis rosea, symptoms of, 198 
etiology of, 198 
pathology of, 198 
diagnosis of, 199 
prognosis of, 200 
treatment of, 200 
rubra, 187 
rubra aigu, 187 
rubra pilaris, 201 
simplex, 71 
versicolor, 315 
Plica, 100 

polonica, 100 
Podelcoma, 328 
Poliotes, 99 
Polish ringworm, 100 
Polydrosis, 61 

Polypapilloma tropieum, 440 
Polytrichia, 92 
Pompholyx, 260 
Populus eandicans, 608 
Porrigo contagiosa, 332 
decalvans, 105 
favosa, 297 
furfurans, 304 
hirvalis, 332 
lupinosa, 207 
Port wine marks, 458 
Post-mortem pustule, 350 

warts, 361, 478 
Pox, 384 

Premature baldness, 102 
Prickly heat, 67 
Primary lesions, 20 
Prurigo, 226 

symptoms of, 226 
etiology of, 227 
pathology of. 227 
diagnosis of, 227 
prognosis of. 227 
treatment of, 228 
ferox or agria, 220 
mitis. 226 
Pruritus. 222 

symptoms of, 222 
etiology of, 223 
pathology of, 223 
diagnosis of, 224 
prognosis of, 224 
treatment of, 224 
sestivitis, 223 
ani, 223 
essentialis, 222 
hiemalis, 222 



INDEX 



661 



Pruritus aarium, 22:t 
palma et plants, 223 
progenitalie, 22.! 

scroti, 223 
senilis, 222 
vulva-, 223 
Psora, 177 
Psoriasis, 177 

symptoms of, 178 
etiology of, 180 
pathology of, 181 
diagnosis of, 181 
prognosis of, 183 
treatment of, 183 
annulata, 178 
diffusa, 178 
figurata or gyrata, 178 
guttata, 178 
inveterata, 178 
linguae, 484 
nummularis, 178 
of the nails, 179 
of the scalp, 179 
of the scrotum, 179 
ostreacea, 178 
punctata, 178 
rupoides, 178 
universalis, 17S 
verrucosa, 178 
Psorinum, 008 
Psorospermose folliculaire vegetante, 

470 
Pterygium, 115 
Pulex irritans, 293 
penetrans, 293 
Pulsatilla, 009 
Purpura, 234 

symptoms of, 234 
etiology of, 237 
pathology of, 237 
diagnosis of, 238 
prognosis of, 239 
treatment of, 239 
fulminans, 238 
hemorrhagica, 235 
medicamentosa, 237 
neonatorum. 237 
papulosa, 230 
rheumatica, 236 
senilis, 237 
simplex. 235 
urtieata, 22!) 
Pustular scrofuloderm, 371 
Pustules, 24 



Quigila, Ml 

Quinolce'a disease, 229 
OBdema, 233 

Radiol herapj . 1 1 
Ranunculus bulbosus, 610 

Pay fungus, 327 
Raj naud's disease, 280 
Recurrent fibroid of the skin, in: 
Perm rent summer eruption, 258 

Reedy nails, 1 17 

Reticular layer of the eorium, l 

Phinophyma, 240 
Rhinoscleroma, 351 
Rhododendron, 01 1 
Rhus tow, ci I 
Ringworm, 302 

of the heard. 30.") 
of the body, 303 
of the scalp, 304 
Pitter's disease, 182 

Rodent ulcer, 487 

s\ mptoms of, 487 

el iology of, 488 

pathology of, 4S!) 

diagnosis of, 4^.1 

prognosis of, 480 

treatment of, 490 
Ron t gen ray dermatitis, 141 
Rosacea, 239 

symptoms of, 239 

etiology of, 240 

pathology of. 240 

diagnosis of, 241 

prognosis of, 24 1 

treatment of. 241 
hypertrophica, 240 

Pose. 444 

Roseola urtieata, 391 
Rum'ex crispus, 013 
Rupia escharotica, 185 

Sabina, 014 

Saccharomycosis hominis, 322 
Salicylic acid, til 5 
Sarcoma cutis, 495 

idiopathic multiple pigmented, 490 

nielano, 495 

non-melanotic, 486 

primary non pigmented, 496 

primary pigmented. 485 
Sarcomatous generalis, 488 
Sarsaparilla, 615 
Satyriasis, 429 



*i 



>,. 









652 



INDEX 



Scabies, 283 

symptoms of, 283 
etiology of, 284 
pathology of, 284 
diagnosis of, 285 
prognosis of, 286 
treatment of, 28C 
crustosa, 284 
Scales, 24 

Scars, diagnostic significance of, 453 
Sclerema adultorum, 268 
neonatorum, 217 
of the new born, 217 
Scleriasis, 268 
Scleroderma, 268 

circumscribed, 271 
symptoms of, 271 
etiology of, 272 
pathology of, 272 
diagnosis of, 273 
prognosis of, 273 
^^ treatment of, 273 
diffused symmetrical, 268 
symptoms of, 268 
etiology of, 270 
pathology of, 270 
diagnosis of, 270 
prognosis of, 270 
treatment of, 270 
neonatorum, 217 
Sclerbdermia, 268 
Scrofuloderma, 369 

symptoms of, 369 
diagnosis of, 372 
prognosis of, 372 
pathology of, 374 
treatment of, 380 
verrucosum, 361 
Scrofulous gummata, 369 
Scurvy, 236 
Sebaceous cyst, 83 
flux, 70 
glands, 6 
Seborrhagia, 70 
Seborrhcea, 70 
sicca, 70 
oleosa, 72 

etiology of, 76 
pathology of, 76 
diagnosis of, 76 
prognosis of, 78 
treatment of, 78 
capitis, 71 
congestiva, 73 



Seborrhcea corporis, 71 

eczemaformis, 74 

faciei, 71 

generalis, 72 

papulosa, 72 

psoriasiformis, 74 

genitalium, 72 
Seborrhceic dermatitis, 73 
symptoms of, 73 
etiology of, 76 
pathology of, 76 
diagnosis of, 76 
prognosis of, 78 
treatment of, 78 
Sebum, 16 
Seeale, 616 
Secondary lesions, 25 
Selenium, 617 

Senile atrophy of the skin, 277 
Senile baldness, 105 
Sensation, 18 
Sensory disturbances, 220 
Sepia, 617 
Shingles, 245 
Silicea, 619 
Simulia, 294 
Skin cancer, 486 

Smoker's patches of the mouth, 484 
Spigelia, 622 
Spilosis poliosis, 99 
Splenic fever carbuncle, 347 
Splitting of the hair, 95 
Spoon nails, 117 
Spotted sickness, 323 
St. Anthony's fire, 444 
Staphysagria, 622 
Stearrhoea, 70 
Steatoma, 83 
Steatorrhea, 70 
Stillingia, 624 
Stratum corneum, 6 

granulosum, 6 

mucosum, 5 
Strophulus albidus, 82 
Strumous dactylitis, 370 
Subcutaneous scrofuloderma, 369 

scrofulous gummata, 369 

tissue, 3 
Subjective symptoms, 19 
Sudamina, 66 
Sudatoria, 61 
Sudolorrhoea, 73 
Sudoriparous glands, 7 
Sudor urinosus, 63 



INDEX 






Sukha pokla, 281 
Sulphur, (>24 

Sulphuric acid, (>27 

Superfluous hair, 92 
Sweat, 16 

eczema, <>7 
Swelling and bursting of the hair, 90 
Sycosis, 336 

symptoms of, 33G 
etiology of, 338 
pathology of, 338 
diagnosis of, 330 
prognosis of, 339 
treatment of, 339 

barbae, 33(5 

capillitii, 112 

framboesia, 112 

lupoide, 338 

"non-parasitic," 330 

parasitica, 305 
Symmetrica] gangrene, 194, 2S0 
Symptomatic premature alopecia, 102 
Symptomatology, 19 
Syphi lidos, 380 

absence of pain or itching in, 389 

action of mercury on, 389 

acneform, 400 

annular. 39.3, 400 

cicatrices of, 389 

circinate, 395 

classification of, 390 

color and pigmentation of, 388 

course of, 380 

crusts of, 389 

deep serpiginous, 412 

eethymaform, 402 

erythematous, 391 

etiology of, 421 

exanthematous, 391 

gummatous, 408 

impetigoform, 400 

lenticular papular, 392 

location of, 388 

macular, 391 

maculo-papular, 391 

marmoraceous pigmentary, 414 

miliary papular, 392 

moist papule, 397 

nummular, 394, 395 

order of evolution of, 387 

papular, 392 

papulo-squamous, 394 

papulo-squamous of palms and 
soles, 390 



Syphilides, pathology of, 421 
pemphigoid, 104 
pigmentary, 4 13 

prognosis of, 423 
polymorphism of, 

purpuric. 414 

pustular, 3!is 

retiform pigmentary, 414 

rupial. 403 

scales of, 3S9 
serpiginous. 1 12 
stellate, 395 

superficial serpiginous, 401, 412 
tubercular, 4iu 
ulcerative tubercular, 407 

ulcers of, 389 

varicellaform, 390 

trariolaform, 399 

vegetating, 412 

vesicular, 399 
Syphilis, 384 

congenital, 4 IS 

hereditary. 4 IS 

infantile. 41S 

initial sore of. 385 

precocious malignant, 388 

rapid benign, 388 

retrogressive, 388 

tertiary, 405 

treatment of, 424 
Syphilitic alopecia, 415 

fever. 386 

lesions of mucous surfaces, 410 

leucoderma, 414 

lupus, 407 

nail affections, 415 

pit \ riasis, 395 

psoriasis, 394, 395 

roseola, 391 
Syringomyelia, 282 

Tarentula cubensis, 028 

Tattooing. 123 
Telangiectasis, 458 
Tellurium, 028 
Terebinthina, 629 
Tetter, 156 
Thuja. 629 
Tinea barbae, 305 

circinata. 303 

decalvans, 105 

favosa, 297 

imbricata, 318 

s\ mptoms of, 318 






654 



INDEX 



Tinea barbie imbricata, etiology of, 319 
pathology of, 319 
diagnosis of, 319 
treatment of, 319 
lupinosa, 297 
nodosa, 96, 98 
sycosis, 305 
tontends, 304 
tonsurans, 303 
trichophytina, 302 
symptoms of, 303 
etiology of, 306 
pathology of, 306 
diagnosis of, 308 
prognosis of, 309 
treatment of, 309 
unguim, 303 
vera, 297 
versicolor, 315 

symptoms of, 315 
etiology of, 316 
pathology of, 316 
diagnosis of, 317 
prognosis of, 318 
treatment of, 318 
Tokelau ringworm, 318 
Trade eruptions, 154 
Treatment, 38 
causal, 38 
physiological, 39 
pathogenetic, 39 
mechanical, 40 
operative, 42 
Trichauxis, 92 
Trichiasis, 95 
Trichoma, 100 
Trichophyton, 306 
Trichophytosis, 302 
barbae, 305 
capitis, 303 
corporis, 303 
Trichoptilosis, 96 
Trichosis plica, 100 
Trichoxerosis, 95 
Trichorrhexis nodosa, 96 
Trophic ulcers, 280 
Tropical phagedenic ulcer, 353 
Tubercle bacillus, 358 
Tubercles, 22 

Tubercular diseases of the foot, 328 
dolorosa subcutanea, 457 
ulcers, 359 
Tuberculin eruptions, 144 
Tuberculosis cutis, 358 



Tuberculosis cutis, etiology of, 372 

general considerations of, 358 

pathology of, 372 

treatment of, 375 
cutis orificialis, 359 

symptoms of, 359 

etiology of, 360 

pathology of, 361, 372 

diagnosis of, 361 

treatment of, 376 
cutis lichenoides, 382 
verrucosa cutis, 361 
verrucosa, 361 

symptoms of, 361 

etiology of, 362 

prognosis of, 362 

pathology of, 372 

diagnosis of, 362 

treatment of, 376 
Tumors, 23 
Tyloma, 473 
Tylosis, 473 

palmas et plantae, 211 



Ulcers, 26 

Ulcer of the phthisical, 359 
Ulcerative scrofuloderma, 498 
Ulcus grave, 328 
exedens, 487 
Ulerythema, 466 

sycosiforme, 338 
Unclassified lesions, 26 
Uridrosis, 63 
Urticaria, 229 

symptoms of, 229 
etiology of, 230 
pathology of, 230 
diagnosis of, 231 
prognosis of, 231 
treatment of, 231 
acuta, 229 
bullosa, 229 
chronica, 229 
faetitia, 229 
gigans, 229 
hemorrhagica, 229 
oedematosa, 229 
papulosa. 229 
perstans, 220 
pigmentosa. 232 
recurrens, 229 
symptomatica, 230 
tuberosa, 229 



INDEX 






Urticaria vesiculosa, .-'.) 
Urtica mens, « > : J 1 

Vaccination eruptions, 150 
classified, ISO 
diagnosis of, 151 
treat incut of, 151 
Varicella gangrenosum, 195 
Varicose ulcer, li)ii 
Vegetable parasitic diseases, 297 
Vegetation vasculaire, 483 
Venereal wart, 47S 
Verruca, 477 

acuminata. 47S 

cadueea, 477 

digitata, 478 

filiformis, 478 

necrogeniea, 301, 478 

perstans, 478 

plana, 478 

senilis. 478 

vulgaris, 477 
Verruga, 502 

Andecola, 502 

bland, 502 

de Castilla, 502 

de Sangre, 502 

de Zapo o' de quinua, 502 

mula, 502 
Vesicles, 23 
Vespa, 032 
Vespidaj, 294 
Vibration and mechanical vibratory 

massage, 51 
Vinca minor, 033 
Viola tricolor, 633 
Vipera, 634 
Vitiligo, 274 

symptoms of, 274 
etiology of, 275 



Vitiligo, pathology of, 275 
diagnosis of, 275 
prognosis of, 27<> 
treatment of, 27li 

Vitiligoidea, 45.! 

Wart, 477 
Wen, 83 
Wheals, 22 
White nails. 1 17 
Whiteness of the hair, 90 
Wildfire, 444 
Woodtick's bite, 294 

Xanthelasmoidea, 2:>2 

Xanthoma, 4.">3 

diabeticorum. 45.'! 

planum, 453 

tuberculosum, 454 

tuberosum. 454 
Xeroderma ichthyoides, 213 

pigmentosum, 500 
Xerosis, 213 

yaws, 440 

symptoms of. 440 
etiology of, 440 
pathology of, 440 
diagnosis of, 441 
prognosis of, 441 
treatment of. 441 

Zincum, 034 

Zona, 245 

Zoster, 245 

abortive. 246 
gangrenous, 24(1 
hemorrhagieus, 246 
hystericus, 247 
ophthalmicus. 247 



H 233 83 






'K 



9t 






$ 



% 






s* 















a .*SflB* %_/ ,^^ o ^ : v< 







^ A* /jaVaT« 





* y% lip;* /\ l ™* : ** v % 



** ^ \"'W1 



77; •" ,o v 'o. 



''77i * .G v %, * *° • » * ' A 

♦AvSSifcV /'tffeS /^kc^ <?*MkS # 




^o* 



4 °^ 






> 












-** o 




y oV* 



^°^ 








.' 



v o^ 
















•^o* 









'^0^ 



••'* .r 



■a? -h 






V-^' 




v^S' 







»V ^. 
















^ -: 




^ ^ 







4 o^ 


















o V 




^0« 



c u ♦ 




•*» A 



>T o &* iV • : 



- ,o* 

















' A V *^ 







^\ ' 




V 





°o 






^ 







5 5>^ ^ 




■vv 














^v *^l^° vv r^E!^: ^v «^^^° rv 












%, ' 



vv ^E!^(' ^ "^i^^t vv °^ii^; ^'s 








> ^ 







-Ho* 





» " * . V 















^ 'i^' v 




o 















